Referral Rules to Live By (2.20.2026) Save

Hello everyone. This is the RheumNow. Podcast. It is 02/20/2026. I'm Jack Cush with RoomNow.

This week on the podcast, more on combined biologic therapy in psoriatic arthritis, my referral rules when choosing between an orthopedist and a rheumatologist. You might want to argue with me about that. And can I use JAK inhibitors in pregnancy? Dermatomyositis and what we see and what we do. This is an interesting study, it's a combination of two different cohorts, 2,500 from claims data, almost 1,200 from community based electronic medical record claims data.

And these are all dermatomyositis patients. And they found as far as some basic benchmarks here as far as what they observed. Myositis panels were done in about half the patients. That thirty five percent had testing for myositis specific associated autoantibodies. Not surprisingly, steroid use was common in roughly seventy percent between the two.

But the most common drugs that were used in dermatomyositis this was a head scratcher for me hydroxychloroquine led the way, followed by methotrexate, mycophenolate, then azathioprine. Number one: Hydroxychloroquine? Really? What? Now, I have used it in a few people for the skin manifestations of dermatomyositis, but I don't know of any good data about its efficacy in muscle disease.

And there's good evidence of hydroxychloroquine causing flares of dermatomyositis. So I find this one surprising. Again, this is observational data. Methotrexate we all kind of agree with, right? Mycophenolate though We did report last year a cohort study from University of Pennsylvania about comparing mycophenolate to methotrexate outcomes as far as skin outcomes and they were roughly the same.

Okay, that makes sense, but mycophenolate? I don't have anybody on mycophenolate for dermatomyositis. Azathioprine, think most of you are using methotrexate or azathioprine. I use a lot of leflunomide and there's only scant data to support that but my experience says it works really really well. The outcomes as far as hospitalization and bad outcomes these are expressed per 1,000 patient years.

Not surprisingly, hospitalization leads away at ninety two. Malignancy is next at fifteen. Malignancy is more common than ILD. Fifteen versus six per thousand patient years. And myocarditis is really rare at only two events.

So again, I think I like seeing these kind of studies, although they are skewed by being observational data, but it sort of lets me think about what I do and how it compares to what's being done out there in the world. A US biobank registry had lots and lots of patients, looked at, and again, high numbers here, sought to evaluate the associations between osteoarthritis and osteoarthritis endpoints and sleep. And the osteoarthritis endpoints were knee OA, hip OA, knee replacement, hip replacement. Turns out that all of these were higher in people who had less than six hours sleep per night. Moreover, night shift workers, people who worked that, you know, that graveyard shift and who were bouncing around between being night owls and trying to live daytime lives when they weren't working the night shift, these people had a twenty four percent higher risk of knee OA and a twenty eight percent higher risk of knee replacement.

So why is that? What's the association here between sleep, bad sleep and knee? I can't really put it together biologically. I can put it together from the standpoint of people with bad sleep have pain, people with pain seek attention. When you seek attention you get a diagnosis, and then maybe something happens like diagnosis or even surgery.

But it still underscores the importance of sleep. If you as a rheumatologist are not an expert at sleep, you're really not doing a good job. I'm sorry to call you out on this, but I think it is so integral into what we do. It is such a big driver of pain and fatigue. If you do not assess for it and know what to do about it, you're missing a big chunk of the treatment options for your patient.

J Rheum had a full read editorial on what HLA B27 can and cannot tell us. I like this article cause I like gene things. It basically tells you the prognostic and therapeutic implications behind B27. And they noted in this paper B27 is associated with greater structural damage, higher inflammatory burden, better response to TNF inhibitors, and IL-seventeen inhibitors. Now that latter part, that being B27 makes you more likely to respond to TNF and IL-seventeen targeted drugs, I'm not really that familiar with.

They just referenced one reference by Drs. Diadar and Magre, and I couldn't really find much on that. I do know the converse is probably true. If you're B27 negative, you're probably not going to respond as well to those agents, maybe because the diagnosis is less certain. But I certainly would like to know, and hopefully someone will tell me at some point, if I have a true advantage if you're B27 by giving you either a TNF inhibitor or an IL-seventeen inhibitor, and which do I choose?

Wouldn't that be a real advantage when it comes to prescribing? I think a real big move this week was the FDA changed its labeling on hormonal therapy. These are primarily estrogen based, but sometimes combination estrogen progesterone based therapies. As you know, when I was a fellow back in 'eighty four, I started, I think in the early '80s, this whole issue of hormonal therapy posing risk to patients as far as cardiovascular disease, breast cancer, etc, was a big thing, became a black box warning, and really it dramatically changed postmenopausal management. And I gotta say, most of the women were not very happy about this.

And it's been shown that most of that data is probably not true. And now you see these box warnings being removed on six products, most of them being, I think, estrogen, but then there were some progestin only, I think, and there are some topicals. But that's an important move because in the post mental period estrogen and hormonal therapy proved to be very effective at symptom management. And as long as it didn't pose a risk, why not do it? Interesting.

Genentech announced the results of a phase two study of obinutuzumab, their anti CD20 monoclonal antibody that we know was approved for lupus in October. This study, the MAJESTY study, is an open label study comparing obedentuzumab versus tacrolimus in one hundred and forty two patients with primary membranous nephropathy, and found more complete remissions at two years with the anti CD20 drug. Now, again, we know it's approved for lupus, this is going to be a big thing, and lupus management, I thought you should know about this. Lupus patients get membranous nephropathy, but I don't think there were lupus patients in this study because this was primary membranous nephropathy. But the good news is that it worked and it worked with an important outcome, complete remission at two years.

When we were doing in September, I believe it was, our campaign on ILD, there was this argument going around by the experts about the utility of ultrasound in diagnosing ILD. And I thought that was kind of goofy, because I thought you needed I knew that chest x rays were good, but high res CTs were much better and really were the gold standard. And there were some reports of this, so I came across a recent study that looked at seventy three patients with RA who had mild to moderate disease activity and they did both lung ultrasound and high res CTs in these patients. Using high res CT they found ILD in twenty nine percent of But when they used lung ultrasound ILD was found in twenty two percent. That would make the sensitivity of lung ultrasound to be fifty nine percent and a specificity of forty nine percent.

It's non invasive, there's no x-ray exposure, the ROC on this was good, you know, I think that maybe this could be an early screening procedure. But I must say that both ACR guidelines and the recent EULAR guidelines do state that if you're doing screening, the screening procedure of choice is high res CT. But the lung ultrasound, who'da thunk? Rotator cuff injuries we know are something that we commonly see. The prevalence of them goes up with age significantly.

And this study that I put up this week was a study of six zero two individuals with shoulder pains that underwent MRI. The average age was 58. Rotator cuff abnormalities were seen in ninety nine percent of people. Again, I was surprised by that number. Twenty five percent it was pure tendinopathy.

Sixty two percent it was a partial tear of the rotator cuff. And eleven percent, only eleven percent were full thickness tears. The point is, as we look at an elderly population with shoulder pain, is it really worth doing a rotator cuff MRI? Maybe if you're going to do surgery. And if that's the case, why should you be doing it?

Send it to the shoulder guy and let him decide He's going to do the surgery. In the meantime, all you can do is, you know, rotator cuff exercises, physical therapy, maybe local injections. But I think that this finding, with a mean age 58, of ninety nine percent having rotator cuff abnormalities, makes me think twice about ordering MRI in the future before I refer, or as a reason to refer. Speaking of referral, someone said in the last two weeks, Yeah, this person has this problem and I didn't know whether I should go to orthopaedics or rheumatology. So I sort of looked that up.

You know, what are the rules here? What's going on in the real world? Obviously, the decisions are either made by patients or by referring doctors, most of whom are either primary care or urgent care, emergency care. And you know what? There's no rules.

And most of what's out there is kind of idiotic. You know, it says, you know, orthopedics, they get fractures, sprains, strains, and you know, that kind of thing. And that rheumatologists only see autoimmune disease for immunosuppression. Obviously, there's a very big gray area in between. And there's a few papers that look at cohorts that were referred for evaluation.

And, you know, the ones that went to orthopedics, you know, up to 25 or more, they said they should have gone to rheumatology. And that maybe fifteen percent could have gone to Rheumatology or Orthopaedics. And of the ones that went to Rheumatology, it looked like ninety plus percent should have been at Rheumatology, with only a few percent going either way. So I don't think there are any rules on this, so I came up with my own. And it's for you to argue with me.

Number one, and again, so this is something I would say to patients. This is something I would say to my primary care docs who want some instruction. Number one, anyone with a history of trauma, fall, you know, that sort of thing should go to the orthopedist or to emergency medicine, meaning the emergency department at your local hospital. That makes sense. You need to rule out structural damage, or in serious surgically corrected correctable conditions.

People with nagging or chronic musculoskeletal symptoms, that would mean more than six weeks, I think that they should first go to a primary care doctor and then let primary care doctors refer to either ortho or rheumatology. And you would say, Wait, primary care doctors don't know who to refer to. Well, that's what these rules are for. I'm honoring them and you know, there's, what, fifty nine million people in The United States with osteoarthritis, you know, ten million with gout, and, you know, seven million with fibromyalgia, and one million with RA, and one point four million with psoriatic arthritis. Come on.

We can't see these people. We need a gatekeeper, and primary care should be doing that and doing that well. Number three: large joints. Primary That's complaint: shoulders, hips or knees. I say it's a toss-up between ortho and room, but if there's a discernible deformity contracture, or an abnormally enlarged joint, I think orthopedics should be first.

And number four: If it's small joint musculoskeletal problems hands, fingers, wrist, elbows, ankles, feet and toes the rheumatologists are the choice to go to. Especially if there's signs of swelling, inflammation and no history of trauma. My last recommendation is spinal problems should go to spinal specialists. Neck, low back, whole back, go to a spine specialist first, or a rheumatologist second, or an orthopedist third. I think this one we might want to argue about, but I think rheumatologists are adept at going through what needs to go to orthopaedics, what may need to have neurosurgery, that sort of thing, and be a good gatekeeper for the system.

So anyway, these are my recommendations. I'd like to know what you think about them. I think another big report, this came out this week, this was a press release from Lilly about their Together PSO trial. This is a trial of two seventy four patients with plaque psoriasis, moderate to severe plaque psoriasis, with obesity, who were then treated either with IL-seventeen inhibitor, ixekizumab, or the GLP-one drug, tirzepatide, or the combination was compared to IL-seventeen alone, ixekizumab. This is a phase 3b study, the thirty two week endpoint was read out that's showing superiority of the combination over the single drug.

The primary endpoint here was a combined endpoint of an ACR I'm sorry, a PASI one hundred plus greater than 10% weight loss. That was achieved with the combination drug by twenty seven percent. If you were just on ixekizumab, only six percent got better. If you just look at the Posi one hundred alone, it's forty one percent versus twenty nine percent combination versus ICSI alone. This is just like what we reported previously in the Together PSA trial that I'm talking about previously reported the Together PSA trial that showed the same results with a combination therapy thirty two percent versus less than one percent for ixekizumab at thirty six weeks.

Both these trials are only out as press releases, they're going to be presented at a major medical meeting coming up in the future, or they're also waiting on the primary, the full endpoint of the study, which is week 52, I think this is a major advance in therapy. Lastly, great lecture last week at RWCS by Uma Mahadevan from UCSF on information about pregnancies. I got up and asked her a question. It was interesting to me that the guidelines on drug use during pregnancy looked to me like the guidelines for drug use during surgery. One) continue all the DMARTs two) maybe either continue or suspend for a brief period, one dosing interval, the biologics and for surgery, the JAK inhibitor question is that you have a brief suspension.

But in pregnancy, you don't use, according to Doctor. Mahadevan. And the reasons I researched and wrote about in an article, and the bottom line is that the ACR recommendations on reproductive health really didn't have a guideline on this, but they noted that there is no available evidence regarding the use or safety of the new small molecule agents, and they pointed out tofacitinib, baricitinib and epimelast during pregnancy, really for a lack of data. But they also point out that these drugs do cross the placenta and will be in breast milk, and the animal preclinical data shows in very high doses that there's teratogenicity and some ugly effects. But there are sporadic reports in the literature about they can be successfully used and whatnot, But again, I do find it surprising since tofacitinib was first approved in 2012 and the last one upadacitinib six years ago, 2018 I think, that there's no more better no better data.

There's no systematic studies. So, again, the bottom line is you shouldn't use it. And then recommendations from the GI societies and Doctor. Mahadevan who have looked at this basically say that you shouldn't use these, unless there's no option. And then use them with caution.

The package insert basically says don't use them. The upadacitinib package insert says that pregnancy testing should be considered prior to the use of upadacitinib. Doesn't mandate it, but it says it should be considered. So, I found Doctor. Ma Devins' lecture really exciting and useful, And then I think this data is a follow-up to it that I think is instructive when managing patients who want to get pregnant or who are pregnant.

I hope you found this interesting. I hope that you enjoyed RheumNow Live. If you weren't there, you can still actually sign up and get on demand access to all the lectures, the videos, the podcasts, the downloads and whatnot, by going to roomroomnow.live and that's so you can get that information secondarily. Anyway, we'll be back next week. Take care of yourself.

Bye.