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Hey. It's Monday, and this is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by our coverage of virtual ACR twenty twenty. RheumNow is where you can go to read, view, listen, vote, discuss, and sign up for emails on the topics that you like most for this year's meeting.

Check it out. Our case this week is episodic arthritis. The gal is a 42 year old white female who's had a seven year history of intermittent arthritis, almost always affecting the left ankle, sometimes the right ankle, and rarely the knees. She has a history of nail psoriasis only. She's been worked up in the past by two different rheumatologists, and been treated with nonsteroidals, prednisone, hydroxychloroquine, really with no disease control per se.

But, workup has been pretty unrevealing, meaning she's rheumatoid factor and CCP negative, she's ANA negative. And since she's seen so many rheumatologists, she's had a lot of tests, you know, so all the negative infectious tests including HBV, HCV, QuantiFERON. She's had a negative ANCA, negative b 27. She does have an elevated sed rate and CRP. The sed rates range from 31 to 80, and the CRPs have ranged from, my goodness, 16 to as high as 82.

She has had a positive Vectra at 56. I didn't order it. So the question is, what does she have? Well, she has palindromic rheumatism. She's been labeled as rheumatoid, reactive arthritis, and seronegative RA, but she really fits the mold of palindromic rheumatism by having episodic attacks, oligoarticular or monarticular, in joints that last for roughly, seven to ten days.

She does get swelling and erythema, and I've actually witnessed these attacks. So what is palindromic rheumatism? It is defined as episodic, attacks of monarthritis or polyarthritis, affecting the joints or periarticular structures, meaning you can get tenosynovitis associated with this. And, of course, the deal here is that there's a subset of these people that will go on to develop rheumatoid arthritis. My chapter in rheumatology, I wrote it's about one third develop RA and then, you know, really one third wax and wane, over the years that they have this, and about one third will remit.

So, this brought brings up a few issues. Actually, there's a recent, study, not a recent study, actually, it's, ten years old from J. Rheum, on the natural history, in a cohort of one hundred and twenty seven patients with palindromic rheumatism, and what they showed is what others have said. If you're factor positive or CCP positive, you increase the odds of going on to develop rheumatoid arthritis. In that study of one hundred and twenty seven patients, exactly thirty four percent went on to develop another connective tissue disease with rheumatoid arthritis leading the way, a few getting psoriatic arthritis or lupus and, and other diagnoses, but they're too few to even mention here.

So what is predictive? In that study, predictive factors for development of another connective tissue disease, mostly rheumatoid arthritis, was first, seropositivity for RF or CCP. Second, PIP or MCP involvement. Those gave about a 2.5 fold increased risk of developing RA. And lastly, femaleness, is that a word?

Had a 2.2 increase, 2.2 fold increased risk such that if you were a woman with hand involvement and seropositive with palindromic RA, you had an eight fold greater chance of developing RA over time. So, in this gal who's 42 and not had hand involvement and she's seronegative, not surprising that after a number of years she hasn't yet evolved. It brings up the greater question, when you see people like this, what are you going to label them? In my lecture that I have on seronegative disease, I think the seronegative actually has a lot of different diagnoses, many that actually stay seronegative RA, but then there's the ones that will progress to another connective tissue disease. There's, and also in this group are undifferentiated seronegative polyarthritis patients.

Those are the ones that will go into remission, once they get treated with steroids or other therapies, and they go into remission. Also in this group, there's a palindromic group, and then also polymyalgia rheumatic, older patients, they're seronegative. They meet they often have, swelling in, hands and upper extremity, joints, so they could meet the definition as well. So how do these people get treated symptomatically? My gal is currently just taking Tylenol, and she has prednisone if she gets an attack.

Interestingly, she has not had an attack in more than a year, that's good news for her. Some people will just take PRN steroids, some people will have frequent attacks, and ones that you're worried about because they are seropositive, they have hand involvement, you might use, medications like hydroxychloroquine or methotrexate, and consider them almost a preclinical RA patient. And by being seropositive, they have a greater than fifty percent chance of progressing to RA, why not treat them? That's palindromic RA. Hope you enjoyed this story.

Tune in tomorrow for another QD clinic. Again, for the ACR, you give us two hours, we'll give you the meeting. Take care. This is QD clinic. Hi.

I'm Jack Cush with RheumNow. QD clinic is brought to you by RheumNow's coverage of the virtual ACR twenty twenty meeting. Did you know Rheumatology Roundup is now gonna be on RheumNow? It's not on the ACR program. It's only on RheumNow.

Tune in Monday night. Me and Artie Cavanaugh digest the meeting. So today's case, undulant fever. Spell that one, and then tell me what it is. It happened in a 28 year old fellow who came to me with a eighteen month history of inflammation, fevers, GI problems, and pleuritis.

So, it was referred because of Still's disease, and that's because I'm the self declared world's expert in Still's disease. No one will fight me for the title. But he didn't really fit the pattern of Still's disease. He did not have a quotidian fever, evanescent rash, and whatnot. Almost two years ago, he started out with, he got sick after returning, from a trip to Central America and came back with, diarrhea and fevers, and then actually was found to have pleural effusion.

Saw, the lung doctors, they did a thoracentesis. He was still having fevers, 101, 102. Work up at that time really didn't disclose anything. He was treated with colchicine, guess what, he got more diarrhea, and then ultimately prednisone, and then he got better. So he got better, he bounced around, ended up seeing a few rheumatologists, was called a lot of different things, including spondyloarthritis.

One rheumatologist did an MRI of his pelvis and showed that he had left inferior sacroiliitis, although he didn't really have much in the way of back pain. He's a young fellow who, is very physically active, does a lot of aerobic activity, and running. And, he was treated with nonsteroidals and and whatnot. And the problem was that, again, this ongoing diarrhea, some chest pain after the pleural effusion resolved. And then he kinda went into remission, was still on prednisone, and while on tapering dose of prednisone was again hospitalized with five days of, again, high fever up to a 103.

And at that time, he, had very high LFTs, you know, five, six fold elevation of l f of AST and ALT. Again, was treated with prednisone, got better, was discharged. Workup really was negative for everything, serologies, B27, you know, rheumatoid factor, ANCA, all that stuff was done. Infectious workup was done, nothing was seen. When he came to see me, we did a few more things.

We did some gene testing that proved to be negative, and we sent off a Brucella antigen. Now, why Brucella? Well, I've been trained here in Dallas, Texas, and, it didn't take long before I came here that I heard about Brucellosis, not from a Warren Zevon song, but instead from patients who would travel to Mexico, eat unpasteurized cheese or dairy products, come back with back pain, uveitis, and fevers, and the fever pattern is an undulating fever, so it's called undulant fever or Malta fever. And you can prove the diagnosis either by tissue biopsy or by doing just a serologic assay for IgM brucella, antibodies, or in this case, in this fellow, he had IgG high titers of brucella antibodies. Now could he have, a spondyloarthritis?

He has unilateral sacro sacroiliitis. He does not have inflammatory back pain. He has had, during that last hospitalization with high fevers, he had a red swollen eye and, was found to have iritis. What else? No other features that would go along with spondyloarthritis, just the sacroiliitis and the iritis, and he's B27 negative.

But does brucellosis, do they get uveitis? Yes, they do. Do they get pleuritis? Yes, they do. Do they get GI symptoms?

Yes, they do. Again, they tend to have chronic SI pain, this guy did not. He said he had some pain there, but he always equated it to his exercise. Anyway, an unusual diagnosis, probable brucellosis, and should be thought of in patients traveling to Mexico or Central America. Again, Brucella is a worldwide disease.

The most common form of Brucella is not from the cow, like we experienced in Mexico, and patients who go there, that's Brucella abortus coming from cow, but the most common is coming from goat worldwide, and that's Brucella militensis. There's also Brucella suis from pig. Treatment of this diagnosis is serologic. This can be suspected by radiology or by pathology. The treatment is going to be four to six weeks of doxycycline, usually with a second agent like rifampin or trimethoprim sulfamethoxazole.

Labs are, other than the LFT elevations, occasional leukopenia, lymphocytosis, really not that very revealing until you get the serologies. Thought you'd like to hear about an interesting case. You wanna hear about more interesting cases? Go to ACR. RheumNow is going to do a lot of interesting things.

You need to think about whether you're gonna sign up for topic reports. We'll send you an email of all the things that you're interested in. If you're a lupus guy, we're going to send you all the lupus reports. If you're a spondyloarthritis gal, we're going to send you all the spondyloarthritis reports in an email. You can sign up for our mid meeting, evening recap on Saturday night.

That's gonna be fun, or you can sign up for our rheumatology roundup, as I mentioned earlier. Look for our emails on this. Bye. This is QD clinic. I'm Jack Cush with RheumNow.

QD clinic is brought to you by RheumNow's virtual coverage, where we give you a front row seat to what everyone's saying about virtual ACR twenty twenty. That includes key opinion leaders, RheumNow faculty, people you know and trust. Today's case is biologics in pregnancy. Saw recently a 19 year old gal who has Still's disease is taking anakinra and a DMARD, let's just say hydroxychloroquine. And the question is, what do I do?

I'm twelve weeks pregnant or I'm three weeks pregnant, and should I stop my medicine? Should I continue my medicine? And, of course, the OBGYN is not going to know. If you have a great OBGYN, they will call you. If you've got a well trained patient, they will call you.

I think the issue here is what are you going to do to get the right ask or direction when they do get pregnant? That is training, meaning that is a discussion between you and your patient who's of childbearing potential saying, if you get pregnant, call me, I'll tell you what to do. If you get pregnant, tell your OBGYN to call me, I'll tell them what to do. So, this was easy. The patient, has well controlled disease, she was told to continue her medicines which are safe during pregnancy.

And, basically, most of our biologics are safe during pregnancy, although there are no studies to truly prove that. There's a lot of data on TNF inhibitors in pregnancy, and it looks very, very good. There's a lot of data on a lot of DMARDs. The only drugs you shouldn't use that are absolutely verboten during pregnancy is number one number one, number two, number five, mycophenolate. That's our biggest offender.

That's our biggest teratogen. Most people think methotrexate and leflunomide. Yes. You don't take those during pregnancy because of what they might do to the baby, but in fact, there are a lot of case reports of successful pregnancies conceived on leflunomide and on methotrexate, not so much so for mycophenolate. Same can be said for cytotoxin and other cytotoxic agents.

But everything else, you know, azathioprine, cyclosporine, you know, and all the biologics have been fairly well studied, and it seems like that's something that you need to do. Here are the things you need to know about managing one of your patients who becomes pregnant and is taking anti rheumatic therapy and or a biologic. Number one, the most important thing is to ensure the mater the mother's health and stability. And you know this from managing your lupus patients. They have to go into pregnant pregnancy being stable, unstable meds.

Otherwise, they're gonna flare, their lupus is gonna flare, the baby's gonna have a bad outcome. The baby's outcome is directly tied to maternal health, more so than the drug that the mother is taking. So the drug you use to manage the mother is important in keeping the mother healthy. So you continue it so they'll do well. And so, again, most people think about, oh, the drugs and all the drugs, we need to stop that.

You know, first time moms don't wanna be on any drugs. Funniest thing I ever heard, smartest thing I ever heard was Megan Clouse and I were on a a discussion panel once, and she was talking about first time mothers are like, no. I don't want nothing. I'm taking everything off. On on the other hand, third time mothers, multiparous women, they're like, give me the drugs.

I'll take them, and because they know they're gonna make a baby and they wanna make sure that their disease is well controlled. Second issue, if they're in remission, then you have to make the really difficult decision about whether to stop the drug once they become pregnant or to continue it. There is a reflex, and I must say most rheumatologists with TNF inhibitors, for instance, would let the person get pregnant, and then once it's they're pregnant, they stop. There is a fair amount of observational research out there that shows the women who stop versus the women who continue, the women who continue do better. The women who stop tend to have a few more complications of pregnancy, not so much, you know, dangerous things happening to the fetus, but, you know, more problems in the pregnancy, premature delivery, abnormal deliveries, things like that.

So, might be better to continue a medicine that's working really, really well. Don't rock the boat. Something that most rheumatologists don't think about, and that is once you're beyond week ten of the pregnancy, you can use any drug you want to use, including cytotoxics, because you don't want to have those drugs on board during organogenesis. And that's really the first eight weeks. So, beyond ten weeks, beyond twelve weeks, you can start abatacept, you can start cyclosporine, you can start tacrolimus, you can start whatever you need to start to control the disease because remember, maternal disease control is paramount to making a good baby.

Next, nonsteroidals. You can use them throughout. You can use them to conceive, probably not celecoxib, some negative data about conception and celecoxib. But the FDA came out with a recent guideline saying no nonsteroidals should be used in the third trimester. It promotes a lot of maternal disease, including hypertension and proteinuria, and then, of course, premature closure of, the ductus arteriosus leads to problems with the baby in and around delivery.

So nonsteroidals beyond the third trimester really should be, off the table. Again, I think it's important to you that you see the patient during pregnancy. Often when they get pregnant, we never we don't see them until, you know, they're flaring postpartum because all drugs are stopped. I think it's important that you see the patient throughout the pregnancy, each trimester, and in the least, the first trimester, to give them education about what to expect, what's gonna come up, and in the last trimester, and then lastly, postpartum. Usually, about six to twelve weeks postpartum unless problems arise.

There is no specific magical drug to take during pregnancy. If you're on a TNF inhibitor, yes, Cimzia would be better than, Enbrel, and Enbrel will be better all than all the rest of them. But you can pretty much be on any of them, and you just have to watch the child in and around birth. And lastly, ACR came out with a, guideline paper on reproductive health. The paper was authored first author was Lisa Samaritano from HSS in New York.

I was on the the guidelines group. It was a a long, arduous, very difficult, task that the faculty, that the authors who comprise that group worked really, really hard. Again, my congratulations to Lisa and her core of leaders that we, helped out on in coming up with a really big, big, big paper. It's dense with information. You should download it and have it on your desk so you can refer to it.

It's got all the information you need about preplanning, counseling the patients prior to pregnancy, conception, you know, things like, you know, preserving sperm and eggs and, what to do postpartum and breastfeeding. It's all in there. It's a it's a, again, a great evidence based document that you should all know about. That's it. Be sure to follow us during ACR next week.

You give us two hours. We'll give you the meeting. Tune in for more QD Clinics. Hey. This is QD Clinic.

I'm Jack Cush with RheumNow. This QD Clinic is called, you are so not disabled. QD Clinic is brought to you by RheumNow's coverage of ACR twenty twenty. You give us two hours, we'll give you the meeting. You are so not disabled is kinda what a lot of people think when patients start asking for that disability letter.

Could you please do this letter for me and whatever, and, you know, doesn't really matter who the patient is or what the diagnosis is. We're like, Oh my God, really? I don't wanna do this. Didn't go to medical school nor rheumatology fellowship, or any of my career has been spent doing disability letters. It's not what I do, it's not what I should have to do.

It's sort of like, like you can say, yes or no, this person is smart enough to move ahead, or this, yes or no, this person is disabled enough to get the letter. It's, again, it's very, very difficult. This came up recently with a 50 year old gal who has lupus, and, you know, she's having trouble. The last six months have been really difficult on her, and she probably had COVID before COVID was a thing and diagnosable. And now she's dealing with a lot of skin disease, loss of hair, you know, more rash, more arthritis, arthralgia more than arthritis, cognitive problems, and she's got new renal insufficiency, and she's got a really important job that she just can't function in, and should she be disabled?

So, again, the question of disability sort of depends on, you know, who it is and what they do, and, you know, and do they deserve it? That's what part you don't want to do. You don't want to get into do they deserve it? Everybody deserves it. Everybody deserves it, and and everybody deserves your support and instruction.

It is far easier to say, no, I'm not writing that letter, and yet and I want you to continue to work because that's easier on you, is it not? But you're not living in their shoes. You don't really know what they're going through. I've kind of had a change of heart on this in the last year or two, especially during COVID when we started getting all these letters, requests for, you know, do you write a letter saying the patient has an autoimmune disease and is at risk and they shouldn't go back to work or school? What I've said is, it's my job to support the patient, especially during times like this, when there's so much uncertainty and so much worry, do the right thing, write the letter, support the patient.

It is part of managing a disaster, doing what you can. Patients who are asking for disability are kind of in a disastrous situation. So, you know, and I get it that you don't want to do it, I mean, I have patients who want me to write for a wheelchair or an electric scooter for them, and I say no, because if I put you in that wheelchair or electric scooter, you're gonna get disabled. You're gonna get weaker. Weak people do less.

If you do less, you get weaker. If you get weaker, you're in a wheelchair for the rest of your life. I want them to be strong. I want them to force themselves to walk with a walker and to go to physical therapy and be all that they can be. But in some people, this does ultimately get down to being, doing the disability letter.

So let's talk about the hard part. The hard part is number one, writing the letter. I'd rather just shoot myself than have to write one of these disability letters. But you know what? You can fix all that by just writing a good template and then filling in the blanks on each patient.

If you've got a good template to write a disability letter where you're putting in there the things that are most important that are justifiable by their disease, then they get this ability with your testimony. Do you have to actually say a certain thing? They're they're missing one and a half eyeballs and a and a a and a left tibia? No. It's not a formula like that.

The formula is what the doctor says. If you can make a case for it, being the authority that you are. So have a good template that you can rely on. It makes your life easier. How do I know what to write?

Second thing, I mean, I don't know what to put in there. Start with the patient. Why do you need disability? What is it that you can't do in your job that we can't fix? And if you're convinced that they've tried, and they've especially taken your advice, and done things that they really should do, on the side of the patient when it's a toss-up.

It's the right and kind thing to do. Again, ask them, what is it that you want me to do? And then you can declare that activity, that task that they can't do, and how it's backed up, and infringed upon by their disease. So, again, it depends if they're stuffing envelopes, anybody can stuff envelopes, but what if you got worsening scleroderma, you got digital ulcers and you're missing a few fingers? Not so easy.

What if you work at the checkout stand and you've got PMR? Not so easy. What if you're a police officer and there's a lot of desk work and that actually is what kills them? So again, you have to sort of, be permissive in what the patient says, is disabling them. You have to be along on the ride.

Is it doing the right thing? Again, we can easily just continue to think like, You are so not disabled, and I am so not writing this letter. But that's not the right thing to do. Do the right thing. And lastly, I ain't getting paid for this.

Well, you can get paid for this. When I ran my own clinic, it was $50 for me to fill out any of such forms. Cash, pay write the check, it's not going to be paid by paid for by insurance. It's an infringent upon my time, should get paid for it because I got to look stuff up. Even if I got a template, I gotta look stuff up.

It takes time. In my institution, they don't charge for it, but someone else is actually gonna do a lot of the work for me. You can actually get paid for this by scheduling a visit. Make this a 99214 visit, do, you know, check a few things, squeeze a few joints, but spend most of your time filling out this form to the patient's satisfaction. And, of course, always keep copies of everything you do, whether it's an FMLA paperwork or a disability paper.

Again, disability, some people need it, and they need you to get it. Do the right thing. Hey. Let me tell you about two things we're doing cool in covering the ACR. One, rheumatology roundup, Arty Cavanagh and I, Monday night, 7PM.

That's gonna be the, November 13. And on Saturday night, midway through the meeting, we're gonna have a mid meeting, sort of, wrap up, if you will, or look in at the meeting and see what's been presented so far and what's coming up. That's gonna be a Saturday night thing at 7PM. It'll be a Zoom meeting. Those of you who, are verified rheumatologists, you'll get an invite to me to attend both of those events.

Those of you who are not, but follow us on RheumNow, you can actually watch both of those presentations where we're getting a lot of questions from people and field those. You can watch those on our YouTube channel or on our website where we're gonna livestream them from, again, 7PM on Saturday night and on Monday night. That's 7PM eastern time, 5PM Pacific time. We think that's 8PM eastern time, 7PM central time. Hope I said that all that right.

Tune in. Take care. Bye. This is QD Clinic, and I am doctor Jack Cush, and you are here because we're having fun. QD Clinic is brought to you by our coverage of ACR twenty twenty.

Our case today is dealing with surgeons. So a 54 year old fellow who's got well controlled rheumatoid arthritis taking a JAK inhibitor, which he says has dramatically changed his life. He's really taking no other medicines, and he's gotta go and have some neck surgery. And, he didn't tell me of this because it was gonna it was about three or four months after I last saw him that he had it done. It was right after COVID.

And so what's happened? His neck surgeon, the neurosurgeon, gave him all the instructions on how to prepare for this and what to do with his anti rheumatic medicines. They told the patient, Oh, we called Doctor. Cush, and they said that you should stop your JAK inhibitor for one month before and two months after because it impairs wound healing, or it can cause an infection, or it's because this is what I do because I'm the surgeon. My goodness, it's the most disastrous thing that can possibly happen.

So, this is how I deal with it. First off, you know the research here. The literature is very clear. All DMARDs should basically be continued all throughout surgery. There's really no reason to stop.

Steroids should be continued throughout surgery, and really, there's no reason to use stress doses of steroids anymore. That's been proven not to be beneficial or effective, just gives the patient more steroids than they need. Biologics, the rule is stop for one dosing interval. So, here's some particulars. One, let's talk about nonsteroidals.

That's very clear. Nonsteroidals aspirin, seven days before, and and and then they can resume them as soon as they get home. When it comes to, DMARDs, and even most biologics, I tell the patient, listen, talk to the surgeon. Get out your pen, your paper, you know, write things down. Like, when he says do this and do that, and you go, uh-huh, mhmm, and you write stuff down, and you look at it and says, I got it, doc.

And then when you get home, you can take that and you can throw it away, and you call doctor Cush, and he'll tell you what to do. If it's methotrexate, sulfasalazine, whatever, I'll say, take it one week before surgery, don't take it the week of surgery, take it and then restart everything two weeks after surgery's done or when the sutures come out. That's not stopping any drug long enough to get into trouble, and it kind of makes the surgeons happy. It's sort of a compromise between their idiocy and our being hard line and evidence based. That actually works.

That also works for biologics, where the rule is, again, you don't want to be at peak drug levels, you don't want to take your infliximab the day before you have your hip replacement. You want to be somewhere from the peak levels down, but not washed out, because washed out means no drug and inflammation and flare with inflammation. Inflammation drives risk for poor wound healing and or infection. So, you want to be off the biologic for, I don't know, a week or two or four, one dosing interval. It's a q two week drug, be off two weeks.

After the Q4 week, be off four weeks. And then have the surgery, and then restart the biologic when the sutures come out, assuming no infection, no complications of surgery. These work, and the patient needs to know that you're the expert, you're the one who has a plan. Again, you need to sound as forceful and as certain as the orthopedist does, or the general surgeon does. But we know their guidelines are not necessarily based on any evidence.

So, if you're a surgeon and you don't like what I just said, I'll meet you in the parking lot, we'll discuss this. That's it. Tune in to RheumNow and our coverage of ACR twenty twenty. We got a few new cool things that you're gonna see on our website. Every day, ACR quiz.

It's actually called ACR IQ. You can quiz yourself on what happened at the ACR just today. Second, there's ACR chat. You're a psoriatic arthritis guy. You can get involved in ACR chat on things that were just presented on psoriatic arthritis.

What's the other thing we're doing that's kinda cool? You can sign up for topic news. You're a gout person, you're a myositis person. We're collecting information, we're indexing it. You can get a post meeting email that will have all the citations we cover on your disease.

You can go you can sign up for that by going to the website, signing in, and choose your topic under emails. You can get a topic email that'll come to you. It'll come to you Monday night, the last night of the meeting, and you'll get the whole download on all your lupus information for you, lupus. So a few more interesting things that you'll see, but tune in and check them out. Bye.