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Welcome to QT clinic brought to you by RheumNow live. I'm Jack Cush from rheumnow.com. Our case today is my acute gout, also known as why I would never use colchicine. So a patient comes in. Let's say he's 50.

Let's say he's Caucasian, and let's say he has a diagnosis of gout. His diagnosis of gout was made three years ago when he presented with podagra and a uric acid of 8.5 and then went on to have several attacks over the next few years. Each attack lasting five to seven days, usually being the MTP, the tarsus, and then lastly being the knees. He comes into clinic presenting with an olecranon bursitis after having had a recent, pedagra attack and after having stopped allopurinol, which was star started in him to obviously reduce his incidence of gouty attacks. So we have a fellow presenting with an acute attack, now an acute bursitis.

It's red. It's swollen. It's tender. It may have some nodular stuff on the inside of that olecranon bursa, which is fluctuant, suggesting he may have a total body urate load that's higher than we may think. And it wouldn't be surprising if we got labs today, which we did, that would show that his uric acid is normal because forty percent of acute attacks will have a normal uric acid.

So he has been sort of self managing this with, an old prescription of colchicine. He's been told to take it one pill, when he gets an attack and then take it an hour later, and then he can take a third one, but no more than three a day until he is better. He And says that's worked kinda well for him. He's gotten a little bit of diarrhea. He's run out of his prescriptions.

He hasn't gone back to his doctor. And the question is, and how would I manage him? How did I manage him? Number one, I stopped using colchicine when colchicine went from 4¢ a pill to $5.50 a pill, $5.50 a pill. And now that it's generic, it's down to about a buck a pill, which is still about 20 times too expensive for a drug that's been around since for as long as dirt, basically.

It is, it's a time honored, two hundred years of showing that gout, that colchicine works, you know, when the when you give it as some kind of bark extract or as a pill, that you can buy from the pharmacy. But it also has, you know, two hundred years of a storied history of toxicity, Even homicide and suicide by colchicine, IV colchicine was taken off the market because it was too toxic. And, frankly, you don't need colchicine to manage gout. It's an historic drug. I don't use historic drugs to moderate to to manage my modern day medical problems.

If I did, I would just be writing prescriptions for penicillin penicillin, colchicine, steroids, and I write for almost none of those. There's some there are drugs that are so much better, so much more efficient. So an acute gouty attack in my book should be managed by, one, confirming the diagnosis. Two, using steroids. You can use intramuscular steroids.

You can use oral steroids. Use a big dose. Use it for a few days. If you get it early enough, you need treatment for three days, five days. If you get it after they've been going on for, you know, five to seven days, you might need it for seven to ten days to make a monarticular attack go away.

I tend to use prednisone twenty milligrams a day. I can go as high as thirty. I can start out with a Decadron shot followed by fifteen, twenty milligrams a day until they're better, and then you have to figure out what you're gonna do after the acute gout attack. If I can't use steroids because they're a brittle diabetic, because they can't take steroids for some reason, then nonsteroidals are highly effective. You do worry a little bit about renal toxicity, destabilization of of unstable heart disease and and heart failure.

But, honestly, they're just gonna get five days of a nonsteroidal, and that usually works really well. Use big boy anti inflammatory doses. That's fifteen hundred of of naproxen, at least a thousand of naproxen. Come on. None of this two twenty stuff.

And then if you need to, I wouldn't use a short acting nonsteroidals like ibuprofen. I might use meloxicam fifteen milligrams once a day until they're better, etcetera. So it's basically steroids, steroids, steroids, and nonsteroidals. And if you can't use that, you could use colchicine. IV is not available anymore, and you gotta give enough of it probably to cause diarrhea.

But, nonetheless, you could use it. But I honestly haven't used colchicine in a long time and partly because of the ridiculousness of pricing, partly because of the toxicity profile. I do have a few patients who do take colchicine usually for an autoinflammatory disease like familial Mediterranean fever. I send them to Canada to one of the Canadian pharmacies asked me. I'll tell you which one I might use.

I don't wanna say it here. Bernie Sanders may may either endorse me, and, someone else may crucify me for sending my patients to Canada where the drugs are illegal and, God knows, very harmful and illegally made. Well, they're just the same thing as we can get here. You can get drugs fairly cheap there. Cheap ways of getting drugs would be to go to Canada.

Another way would be to, actually use a a GoodRx card or to actually call the pharmacist and figure out a cheaper way to get whatever drug that it is that you want. Anyway, that's it for this edition of QD Clinic. RheumNow, has a fabulous session on, spondylitis that is going to be led on Sunday by Atul Daydar. He's gonna talk about all the latest update on new therapies, IL twenty three, IL seventeen. It's really quite impressive.

Arti Cavanaugh is gonna talk about something you've never heard of but would always wanted to know, and that is enteropathic arthritis, meaning IBD associated arthritis, diagnosis, management, clinical considerations. And then Walter Miksimovich from Edmonton is gonna talk to us about imaging, both radiographic and, MRI imaging and all the mystery around SI joint readings on MRI. There's a lot of new information there. Again, come to Fort Worth on this meeting, 03/13/1415 for a fabulous, set of lectures, including ones on spondyloarthritis. Welcome to QD Clinic.

I'm Jack Cush from RheumNow. QD Clinic is brought to you by RheumNow live. Our patient today, missus DC, is a 42 year old who comes in with a newly diagnosed rheumatoid arthritis. She has a fatty liver. She has diabetes.

She's not responding nonsteroidals and low dose prednisone. She gets put on methotrexate, and after twelve weeks, she has an AST of 47 and ALT of 51. Everyone's a little bit nervous about what to do, and how we can best manage this. The decision is made to put her on a TNF inhibitor and lower her methotrexate, she gets tested with a QuantiFERON test and it comes back positive. She is from The United States, her family is from, Central America, and she has no known contacts with people who have TB.

She has no signs or symptoms. Her chest exam is normal, her chest x-ray was done, and that's normal. She meets the definition of having latent tuberculosis. So the question is, what do you do? You want to put her on a TNF inhibitor?

How do you best manage that? Again, latent tuberculosis is a positive test for TB reactivity. That could be a tuberculin skin test, PPD test, or it could be a T spot, or it could be a QuantiFERON spot. Any of these, especially in a high risk individual, someone born in endemic country, any of those are positive is reason enough for treatment, if they in fact meet the definition of latent disease. You can assume it's latent disease because again they have no signs and symptoms, a negative chest x-ray, and they have a positive test.

Now, you could go one step further in some individuals and culture everything, culture urine, sputum, etc. Because there's a few people, especially high risk individuals born in endemic areas, who still could be positive, and that would change treatment because that would be active TB if they had a positive culture. So, in this patient who needs to be on treatment, what are you going to do? Well, first you should know how frequent this occurs. If you're, running a clinic here in The United States or another non endemic country where the TB rate is roughly less than five per one hundred thousand individuals, the risk of finding a positive PPD or QuantiFERON or IGRA test is about five to ten percent.

It may be five percent, and then if you do it the first time and then repeat it three, six months later or when they switch their first TNF, then you'll find another few percent who will be positive. Those people will have been anergic or may have had an indeterminate result, And then with control of inflammation, they'll get their full immune reactivity back and show you they actually are a latent TB person with reactivity. I do recommend second time testing. I do not recommend annual testing. That is a special kind of stupid.

There's no good reason for it. You should repeat test when risk changes with exposure, for instance. But if you're skippy living in Connecticut with no change in risk to repeat the testing is just not of any value even though it's requested by insurance companies. I do recommend second testing because as I said, there's a few percentage of people who really are latent TBs who would be missed on initial testing. And then when do you what do you do?

You get a positive result, you put them on treatment. What treatment do you put them on? You have several options. There are some newfangled options that you have to come to RheumNow live to learn about. Kevin, Winthrop from Oregon Health Science Center is the infectious disease of the rheumatology stars.

He knows our patients, our business. He'll talk on how to TB manage and test, but he would tell us of some newer regimens. The old regimen is six months of INH grade b evidence, nine months of INH grade a evidence, grade b evidence for rifampin for for four months. I I like rifampin for four months. And with both INH and rifampin, you have to do some heavy TB LFT testing baseline and every month for two months, and then maybe if there's no elevations, you can do it every other month until they're stopped because LFT elevations on those drugs can be disastrous.

The question is, you start someone on treatment for LTBI, when can you start treatment with the TNF inhibitor? The FDA rules on this are in the package insert, and they all say the same thing. Treatment with prophylaxis should begin before treatment with the TNF inhibitor, before. It doesn't say a week before, six months before, nine months before. These are all idiotic recommendations from colleagues, ID specialists, pulmonary specialists.

The FDA, in consultation with the largest division of the CDC, said before, meaning, I can throw three hundred milligrams INH down the throat of one of my patients who has latent TB and then stick an IV in their arm and give them Remicade, and that is okay. I've done that many times. No one's going to reactivate and flare. In fact, they'll just get better with regard to the arthritis, which you thought was so severe they needed a TNF inhibitor. So before means before, not one week, two weeks, six weeks, six months, nine months.

Again, those are all idiotic recommendations. Latent TB is actually really easy to monitor. Patients need to know how long they're gonna be on that therapy, and how and you set the expectations for them. And again, frequent and aggressive monitoring of LFTs are in order. Come to RheumNow.

You can hear Kevin Winthrop lecture on this. Let me tell you some of the comments that we got from RheumNow Live last year. One of the best first days of a conference I've ever been to, a new level of engagement with the speakers at RNL two thousand nineteen. Doctor Seal left us with good clinical thoughts and ideas. It was two and a half fun days of intense learning at RheumNow Live.

Excellent talks and long q and a's. Mike says very slick meeting format. And Thomas says, great job. Love the RheumNow live format. You too could be one of the ones with a rave review.

Go to roomnow.live to register. We have more QD clinics and QD videos this week. Hi. I'm Jack Cush with room now dot live, and this is a preview of room now live, which is just fifteen days away in beautiful downtown Fort Worth, Texas. For you, that's an easy flight to DFW and a twenty minute cab ride, and you'll be at the meeting.

Again, this is going to be 03/13/1415. We start on the afternoon of March 13 with some sessions on rheumatoid arthritis. We start at noon. We go till five. We have a break, and we have a beautiful session out on the roof that we call rheumatology distilled, craft beers, craft wine, craft lemonade for me.

And then it's all day Saturday, half day Sunday, you're back at home. This is our second shot at RheumNow Live. We did it last year to a great deal of accolades and fanfare. It really met our expectations. We designed basically what was going to be the little big meeting.

Little in that we wanted to be small, intimate, not like many other meetings that you probably don't want to go to anymore. ACR, ULAR, you know, 600 person meetings where you're lost in the crowd and trying to keep up on one hour lectures. We wanted to do a meeting that was gonna be little and that was a 120 to and 50 people where you could pretty much know everyone and interact with everyone, including the faculty while you're there. That turns out to be the optimal size for any educational meeting. But it's going be a big meeting in that we're going to also broadcast it live over the Internet for those who cannot attend.

The meeting was designed by Doctor. Arti Kavanaugh from University of California San Diego and myself from UT Southwestern, and we have some fabulous, fabulous speakers. We're most proud of our keynote speaker, Doctor. Nicola Dalbeth from Auckland. She is the world leader, one of the best sources on education and research in the field of gout, but she's going talk about some novel things.

She's to do a TED Talk. She's going to do, a history talk, a history of gout talk. It's going to be a really great session to have her there. So the way we run this meeting, it's different from others, is that our lecturers are asked to give a short lecture. You know, the shorter the lecture, the harder it is, And people then have to focus in on what's really important and clinically applicable.

So they're going to give only thirty minute lectures and then it's allowing two or three minutes for questions. And we're going to have blocks of two hours devoted to RA and another RA session, psoriatic arthritis, ankylosing spondylitis, and auto inflammatory disease, and even lupus. In those two hour blocks, you get three lectures from three world renowned leaders, and then we put them up on stage, we mic them, and we let you have at them. Whether you're remote or whether you're live, you get to ask questions. Whether you're remote or whether you're live, you get to see the questions that are gonna be asked, and you can upvote them or downvote them.

It's really sort of cool technology. The the audience loves it. The faculty love it because it's really very interactive. It's very interactive between the faculty. It's very interactive between the audience and the faculty.

And then we go to break and everyone gets to hang out with the faculty. In between these two hour blocks, we also have something truly unique, not seen in any other meeting, and these are basically TED Talks. We call them STEP Talks standing for science, technology, education, and patience, where those are the things they need to talk about. These can be like TED Talks in that they are smaller packages of inspirational, thought provoking talks, or they tend to be mini lectures very focused on a topic of interest to you, like Joseph Smolin talking about treat to target, something he invented, and now we're like more than ten years down the road. We're gonna hear from him about the success or lack of success of T2T, and that's treat to target.

So these TED Talks, I love. Everybody loves them. You get three in a block between these two hour blocks. It's really quite cool. Our other TED sessions, our other STEP sessions are gonna be on the history of rheumatology.

Bevra Hahn, history of lupus. Daniel Wallace, mister lupus, guess what? He was there in the beginning when they discovered HLA B 27. He's gonna tell that story. And doctor Dalbeth talking on the history of gout.

The masters of the EU, we had this last year. It was fabulously successful. Doctor Gerd Burmester talking about the future of rheumatology. Robert Landaway, are we getting it right? And Joseph Smolin.

Other future rheumatology, practice sort of talks are going to come from Chad Diehl talking about manpower, Alvin Wells, telemedicine, and Eric Newman, something you've never heard. And then we have some new unique sessions. We have two patients, Chris Lindsay, and Amy Leung are gonna talk about the RA and PSA perspective, what you as a doctor need to hear from the patient's point of view. We also have two younguns, two young Turks, are the big podcasters out there, doctor Michael Putman who has the Evidence Based podcast and John Houseman who does the ACR On Air podcast, two great podcasts that I listen to. They're gonna tell you about new ways that you should be learning in practice.

You should come because you'll hear Atul Diadar talking about updates in spondylitis. He's the guy that does all the work. Arti Kavanaugh giving a lecture you've never heard before on the microbiome and IBD and inflammatory arthritis. Walter Maximovich on imaging, he developed the criteria for which people rate, axial imaging, especially spondyloarthritis. Joan Merrill from Oklahoma talking about, lupus nephritis.

Megan Clouse, she's part of this big reproductive guidelines paper, three papers that just came out, and she's going to talk about lupus and pregnancy. Melissa Costner, you may have heard of, I know her well, she's a world renowned, lupus skin person, and she's a fabulous speaker. She's gonna be there talking about mimics of lupus and lupus skin disease. John Giles on cardiovascular disease, Chris Richland on what you need to know that's new and exciting on psoriatic arthritis. Bruce Kronstein, the guy who told us how methotrexate works, is gonna be there to tell us about how methotrexate works.

I'm gonna talk about why you should be worried about seronegative RA. You can still register. There are still some sites left. We're again, we're gonna cap it at 01:50, and, again, it's gonna be a fabulous live meeting. Next week, we will send out invitations for people to register for remote, viewership.

Go to the website, roomnow.live, click on speakers or register to, see the speakers and the agenda or to register for the meeting. And lastly, Fort Worth. It's you know, it sounds like it's Texas. I don't need to go to Texas. I need to go to San Francisco and other neat places.

You go to Fort Worth, you're gonna be really, really surprised. It is a cool town. I'm in Dallas. I chose to do this in Fort Worth, west of me, because it is so much cooler, so much nicer, more relaxed. You know, within a five minute walk, you can see and do about a million things.

It's world renowned for Billy Bobs. It's a honky tonk. It's a mile long and a rodeo wide. It's crazy, but it's truly Texan. It's got the the stockyards where you can see longs longhorn steers.

It's got a great downtown. It's got the most interesting and best Tex Mex at, Joe T. Garcia's, which is not far away. Again, I think the ambiance, the fellowship makes this meeting a great meeting. Hope to see you.

It's just fifteen days away. That's in Fort Worth, Texas, roomnow.live.