RheumNow - ACR 2017 San Diego - Day 3a Save

I'm Alan Gabosky from Hospital for Special Surgery in New York, here at the American College of Rheumatology twenty seventeen meeting in San Diego. One of the more interesting presentations was from a group that looked at the cost of care of patients with a number of autoimmune diseases, including rheumatoid arthritis, lupus, and psoriatic arthritis, as a function of the amount of corticosteroids they were taking. They divided patients from a number of these diseases into low cortisone use, high cortisone use, and medium cortisone use. And I use the term cortisone because they basically took patients and converted every amount of corticosteroid they were taking into a prednisone equivalent. So there were three groups, low, medium, and high, separated by seven and a half milligram intervals.

And what they demonstrated was that the cost of care in the high group was significantly greater than the medium group and even greater than the medium group than the lower group, suggesting that not only would reduction in the use of corticosteroids have a clinical benefit by way of reducing corticosteroid induced complications, but it may very well have an economic benefit as well. So I think the take home lesson from this is that while we are quick to use corticosteroids to reduce flares and manage diseases, we should probably be using corticosteroids at the lowest level necessary for the shortest period of time.

Hi. This is doctor Artie Cavanaugh for RheumNow coming to you from the American College of Rheumatology 2017. This is day three, Tuesday here at the ACR. Lots of stuff. Thinking about what to talk about, I think one of the areas that's always hot is safety.

And one of the issues that has come up is with the new class of oral medications, the JAK and Ibs. And there's been a consideration of whether or not there may be some clots, maybe pulmonary emboli and deep venous thrombosis. There's a couple of posters that have addressed this and surely to be a hot topic of discussion. To follow this, go on RheumNow and see updates on this important topic. As with many things in safety and rheumatoid arthritis, hard to know whether safety events, especially if they're uncommon, are more due to the disease than they are to the treatments.

But it's interesting. It's important. We need to know. So enjoy this, enjoy the videos coming to you from ACR twenty seventeen and we'll see you on RheumNow. Hi, this is Doctor.

Artie Cavanagh coming to you from the American College of Rheumatology twenty seventeen meeting for RheumNow. Today's the last day of the meeting, Wednesday, November 8, and as we've done for a few years now, my friend and colleague Doctor. Jack Cush and I did our Rheumatology Roundup in which we just take a wild tour of some of the more interesting abstracts, usually posters that we saw at this year's meeting. So here's a few that I reviewed, which I think were really good abstracts. One is abstract six sixty one, which was from the group in Leeds.

Dennis McGonigal and his fellow doctor Cushberg presented this. And this looked at gamma delta cells in peri bone in the in the theses that's just about bone from spinal samples. These were patients who were undergoing surgery and they just took the spinal samples and they saw that there was enriched for gamma delta cells. The reason this is important is it actually gives, first demonstration in humans that you do find gamma delta cells in enthesial locations. Now these were not patients with inflammatory arthritis, but I think this is a natural step.

Gamma delta cells can make IL-twenty three. We know that cytokine can be important. I think we look forward to more development on this to teach us maybe how best to approach patients who have certain conditions associated with particularly psoriatic arthritis and the other spondyloarthropathies. Another poster that I really liked was number eleven twelve. Small study, but what it showed was patients who go to the emergency room for a gout flare, they were treated with all different regimens of steroids.

So this looked at high dose sixty, fifty, forty, thirty, twenty, ten, and then stopping or low dose half that thirty, twenty five, twenty, fifteen, ten, five, and then stopping. Turns out that not only do you not need the higher dose, but the people actually did better in terms of getting back to the pre treatment pain level. They did better with the moderate dose as it all of us use steroids a little bit different and I think we all like information that can tell us how to perhaps use them a little better. Another abstract, actually a couple of abstracts, two thousand thirty one and two thousand thirty two, which are right next to each other. Junior faculty member who was questioned by some medical students and said their hypothesis was that patients who look at their labs in the electronic chart maybe do better.

Remember, those people are more involved in their care. And I guess you could take that hypothesis. You could take the alternative that there are people who just look at their lab tests all the time. And they looked at the SED rate, and it did not appear that those people who looked at the labs more often had a greater decrease in their SED rate than did those who did not look at the lab. So with all of us having to use electronic records more and more, I think it's nice to know what information can we get from the electronic medical record.

This certainly includes patient involvement. Patients ought to be involved in their health care and their health care decisions and how best can we integrate them into that and get perhaps better disease control. So it was a nice poster by a young faculty member in rheumatology addressing an issue raised by the students. Really the kind of nice project that we like to see at the ACR meeting. So this is Doctor.

Arti Kavanagh saying goodbye from the ACR twenty seventeen in San Diego and you'll hear much more on RheumNow.

Hi, I'm Eric Ruderman. I'm a rheumatologist from, Northwestern University in Chicago. I'm here at ACR twenty seventeen. We presented a poster actually at this meeting that I'd love to tell you about. Northwestern, has had its own specialty pharmacy for a couple years now, and we were able to go back and look at what happened to the prior authorizations that we ran through our specialty pharmacy.

We were not surprised by the results, but it was pretty telling. We looked at about 3,000 prior authorizations over a little over a one year period, and it turned out about 90% of them were approved on first pass. Of those that went for appeal, about two thirds were approved on appeal, and, ultimately, 94% of every prescription we wrote that required prior authorization was ultimately approved, and this is across rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile inflammatory arthritis, and psoriasis, dermatology and rheumatology. The take home from that is the prior authorization process, which ostensibly is trying to get the right patients on the right drug and make sure the wrong patients don't get on drug, is probably not that. It's really, as we all suspect, a delaying process, to keep people from getting on drug until they absolutely can.

Hi. I'm Jack Cush, executive editor of rheumnow.com. It is Tuesday here at the ACR. We're hitting the home stretch, another busy morning, busy day. I wanna tell you about a presentation I'm gonna do later this afternoon.

It's gonna be a clinical symposia. It's called auto inflammatory syndromes from bench to bedside, or is it bedside to bench? It's we're going to discuss the science of auto inflammatory syndromes with Dan Kastner doing the first presentation, and then I'll be following that up with a sort of clinical approach and therapeutics, and basically showing what we do really from the bedside to the bench in managing these very difficult patients with febrile disorders. I'll cover some of the auto inflammatory disorders, including FMF and traps and the cryopyranopathies, the CAP Syndromes. But I'm gonna get into mainly Still's disease, something I have a long interest in.

Still's disease, as you know, is a juvenile disorder that actually has an adult continuum. And when that happens, we call it adult onset Still's disease. There are no criteria or diagnostic tests. There are some proposed guidelines for diagnosing this syndrome. I like to use the Cush criteria, which says that you need two points for every major criterion.

The major criterion being high fever, spiking daily fever is greater than 39 degrees centigrade is number one. Number two, the evanescent rash, the JRA rash that comes and goes. Number three, simultaneous elevation of white count and sed rate. Number four, seronegativity. And number five, carpal ankylosis, seen in fifty percent of patients, but nonetheless fairly specific for, Still's disease.

For every one major you lack, you get one point for a minor. Age of onset, less than 35. Prodromal sore throat. Involvement of the liver with LFT elevations or what I call RES involvement, reticular endothelial system involvement, that's hepatosplenomegaly, splenomegaly, or generalized lymphadenopathy. Next would be polyarthritis, and then following that would be the development of tarsal ankylosis.

Also, not common, but fairly unique to this condition. The overall approach to these patients with febrile disorders really hinges on the duration of fever. In the case of Still's disease and systemic onset JIA and maybe Schlitzschmidt syndrome, you get daily fever. It's not genetic, and it can occur during adulthood. In the other disorders, it's dependent upon the duration of fever.

So if you have one day of fever, you should think about FCAS, familial cold or inflammatory fever. If you have three days of fever, you should be thinking about either Mucklewell syndrome or familial Mediterranean fever or FMF. If you have two weeks or more of fever, should be thinking about trap syndrome. And so two weeks, most trap syndromes, it's really like two to three weeks and then they go into remission and it comes back. So it is the duration and then the interval.

So the periodicity, the height of the fever, when the fever occurs, these are all very important in making the diagnosis. I'll give you two more pearls about Still's disease. Number one, Still's is a quotidian disorder. It is a truly circadian disorder. The fevers occur either late in the afternoon, but usually late at night, and they occur at exactly the same time every night.

The patients will look at the clock and they'll say, it's gonna come at 11PM because at 10:58 they get shaking chills, then they're and that goes on for twenty minutes, then their fever shoots up, lasts for two or three hours, and then they fever comes down, they defer vest, they sweat, they change their clothes, they change the sheets, and they look pretty good when you see them at 7AM. So a Still's fever is almost never at 7AM. So it is that diurnal, truly circadian, pattern that's very, very important. The second thing is how do you follow these patients? The best biomarker that I've learned from my colleagues at Baylor and at Texas Scottish Rite Hospital is aldolase.

Aldolase goes up significantly in patients with active inflammatory, you often IL-one responsive disease. The CPKs are normal, but these patients do have, elevated LFTs, they do have a lot of myalgias and whatnot, but this is largely liver derived, and it goes up very high, twelve, fifteen, 35, and it'll stay up while they have active disease and come down once you've been effectively treating the patient either with steroids, methotrexate, an IL-one inhibitor or an IL-six inhibitor. Anyway, you wanna know more, come to the session starting at 04:30PM today. It's gonna be in Hall 6 C. We'll see you there.

Tune into RheumNow for more news and videos.

Hi. I'm doctor Janet Pope. I'm at RheumNow at ACR twenty seventeen. I have a little bit of musings about mentorship. When you look around, there are way more than 2,000 abstracts at this meeting.

And there's a lot of trainees. There's people getting into medical school that are doing posters, people in medical school, residents, fellows, junior staff, and everywhere in between, and our allied health professionals and other master's students and PhD students. And I think what's most important is don't be overwhelmed. Many people that are highly successful had to start somewhere. They had the the knocks of life where things were didn't always go their way, grants aren't always obtained.

But if you are really energetic and you're dedicated and you pick the right mentors, I think people at any level can really get into research and do fantastic job. So go ACR twenty seventeen, go RheumNow, and keep the research going. Thank you. Hi. It's doctor Janet Pope.

I'm coming to you from RheumNow at the ACR twenty seventeen. What's really interesting to me today at the meeting is a lot of talk about cancer. So we have in the large safety databases such as long term registries that there doesn't seem to be a signal of our advanced therapeutics with respect to cancer except for non melanoma skin cancer. However, what we have to deal with is many patients with rheumatoid arthritis or other inflammatory arthritis who have now developed cancer. Their chemotherapy is done, and what should we do?

So there was a meta analysis trying to search to give us an answer because we treating physicians are faced with this a lot. And the meta analysis really can't give us an answer. It was doctor, Suarez and her group. It can't give us an answer because we really don't have randomized controlled trials. So I think we'd all like to know your opinion is if a patient with rheumatoid arthritis has cancer, would you go back on treatment?

Would you never treat them again? Would you try a different treatment? Or would you ask the patient? So I urge you to check out roomnow.com and give us an answer for that. Thank you.

Hi, I'm Doctor. Janet Pope. I'm at the ACR twenty seventeen at the RheumNow booth. We're starting to wind down today and I have interesting abstract to talk to you about, number 3,000 377. This is from the early RA cohort, Esquire, from France and there's over 400 patients in this cohort and what they wanted to do is look at radiographic change when they're using various drugs.

We know that if we get the disease under control, that anything could be a DMARD. If we suppress inflammation, we might improve joint damage. What's different about this study and contradictory to a lot of things we've heard is that corticosteroids actually were a poor predictor and had more X-ray damage. We could explain it by the fact that only the worst patients got corticosteroids, but if you look at the EULAR guidelines, corticosteroids have been used as an add on in early RA for a long time in Europe even though the guidelines are recent. So I really wonder if they're channeling bias or confounding by indication, but it makes us think twice, try to control the inflammation with our proper DMARDs and maybe save the steroids for later.

Who knows? Thanks from RheumNow.

Hi. This is doctor Julio Gonzales reporting live from the American College of Rheumatology two thousand seventeen meeting out of in San Diego, California. And I wanna talk about, some clinical findings, in the field of psoriatic arthritis that were reported in the in the last one or two days here in the meeting. Okay? So the first one I wanna briefly discuss was an oral presentation, was an oral poster that was, discussing the topic of, enthesitis in psoriatic arthritis.

So this is a small group of patients, 25 patients on each arm. It was an open label study which compared the use of ostekinumab with the use of TNF inhibition in enthesitis, resolving enthesitis in psoriatic arthritis. What the study showed was that ostekinumab was superior to TNF use in resolving in TCL inflammation in this patient population. This is relevant because this is kind of a hot topic right now in psoriatic arthritis. There was another report presented last June at the EULAR meeting with similar findings.

The role of IL-seventeen and IL-twenty three inhibition in psoriatic arthritis is definitely something to be paying attention to, specifically in enthesitis and psoriatic arthritis. In fact, Doctor. Phil Meiss announced in the GRAPA meeting that there's gonna be a small group of investigators studying this disease or this domain of psoriatic arthritis. So again, this is a hot topic that we need to be looking at. There were also two posters that I want to comment on that were presented yesterday on the spondyloarthropathies, specifically axial spondyloarthropathies.

One of them talked about the use of low dose CT as a possible imaging modality in the spine in patients with AX or AS or radiographic, sorry, axial spondyloarthritis. This study measure CT is in desmophytes, was the score they used, and it showed increased sensitivity as compared to just plain films. The other study was a report on the five year French cohort, the SEER cohort, which showed that after five years patients with early axial spondyloarthropathy had low levels of radiographical progression. So this is relevant because we're all questioning how much these patients will progress which is early disease. And they also noted that the most sensitive measure for detecting progression was fatty changes in the SI joints.

I think that's it for the most part in psoriatic arthritis right now. Tomorrow, there are new National Psoriasis FoundationACR guidelines on psoriatic arthritis will be released, so that's important. That's definitely something to look for. And, if you want any more information, be sure to tune in to rheumnow.com. And, also, I wanna make, make sure that go you guys go check out the Creepy Joints booth where they have a project going for the relief efforts for the victims of the Hurricane Maria in Puerto Rico, especially the rheumatic victims.

So please go check that out as well. Thank you.

So this is Katherine Dow coming to you from ACR twenty seventeen in San Diego. So one of the things that I've learned in the vasculitis session is that there is extracranial solitary or isolated giant cell arteritis and this is a distinct entity or a distinct phenotype from the cranial variety. So the cranial variety you think of an older gentleman with headaches and jaw claudication, fever, malaise, weight loss, and you get a positive temporal body re biopsy, right? So the extracranial isolated or solitary giant cell arteritis can be considered as somewhat different from the cranial GCA and the difference is that these patients are diagnosed a little bit earlier so instead of being diagnosed at age 70 and 80, these patients are diagnosed in their 50s and 60s. The other thing is that a temporal artery biopsy may not be positive in these patients.

In fact, less than fifty percent of temporal artery biopsies are positive in these patients compared to eighty percent in your cranial GCA. Not only that, these patients may also, have more vascular stenosis in the, extremities or in the aorta. So Plavian arteries can also be affected as well. So essentially, this is considered like an emerging entity that we should be able to recognize in the future, perhaps even separate from cranial GCA. There's abstracts on this, topic as well as some data in the literature to support it.

So this is Catherine Dow for rheumnow.com.

Hi, this is Paul Supka, coming to you live from ACR 2017. It's Monday afternoon and this afternoon, I went to a talk by doctor Suleiman Banno, who's a good friend of mine. And he gave his, talk, which was called tech tools for rheumatology version three point o. It's always a great talk and one of my favorite talks of the year. This year, he gave rheumatologists a few of his favorite technology tools, to, take a look at for the office.

And I thought he laid down a set of really good guidelines to, be able to assess whether you you should be looking at trying to purchase some of these things to use. First one, of course, is is the cost of the item. He actually gave a bunch of, very, lower cost than you'd expect technology tools. He said that these have to be usable tools, like they can have a difficult, interface. He said that, they have to change, patient care.

And a few of these tools that I'll just mention, the first one is he mentioned a tool called the Olioclip, which is a little clip that you can attach to your iPhone. And with that, you can actually do nail fold capillaroscopy, for your patients. And it magnifies at such a level that it's really, really easy to do. And then the next thing he described was a tool that was called a FLIR ONE camera, and this is an infrared camera that attaches to an iPhone, and you can actually use it to more easily look at patients that have Raynaud's, and it can actually be useful as well to, look at patients that have inflamed joints because they'll be warmer. So for more information on things like this, go to roomnow.com.

Hi, this is Paul Sufka. I'm coming here from ACR seventeen. I just want to go over a few important abstracts that I've seen regarding treatment of patients with rheumatologic disease who are pregnant. First, I recently saw an abstract talking about, the importance of having our patients, with lupus on hydroxychloroquine or plaquenil. It seems to decrease risk of, early fetal loss, and it also decreases the risk of, preeclampsia.

Besides, it also, as we know, decreases overall lupus disease activity, so that's very important. I also saw a nice study, looking at three fifty patients who were exposed to cerdulizumab pegol during the first trimester of pregnancy. And great news, there is no increased risk of increased fetal loss or other malformations, so very reassuring to our patients. And last, I saw information from a database looking at, people who are exposed to oral corticosteroids or prednisone, during any trimester of pregnancy, And, what it turns out is that all of those patients do seem to have an increased risk of early, delivery, not necessarily increased fetal loss, however. So important aspects for us to be aware of if we're thinking about treating our patients with lupus.

If you need more information, go to roomnow.com. Thanks.

Hi, I'm Philip Romsen from the University of Queensland. I'm here in beautiful San Diego for ACR seventeen. I've just come from a great session on osteoarthritis. And essentially the focus of the session was thinking about how osteoarthritis interacts with inflammation. So there's been lots of work looking at the levels of inflammation in osteoarthritis.

And I've found that these correlate to high progression, so more joint space loss over time. And then if you look in animals, if you treat them with anti inflammatory treatments, like anti IL-one RA, you can actually treat osteoarthritis, but that hasn't been shown in humans. But certainly, if you then look at trials of anti inflammatory treatments, for example corticosteroids, there are some short term benefits in some trials, but the most recent big trial showed a loss of cartilage over time. But then there have been some other more exciting trials looking at things like adalimumab. While the primary outcome was negative, when you looked at things like palpable effusions in joints, there was a significant effect.

And then things like anti inflammatories topically work. So this all comes together, both the basic science and the therapeutics, to say that in the future we might have therapies that are anti inflammatory in nature that that can make a difference in osteoarthritis. So I think watch this space. And for more information, to roomnow.com.

Hi, I'm Doctor. Rachel Tate from Dallas, Texas, and I'm coming to you from ACR twenty seventeen in San Diego. I just attended a really great plenary session with Doctor. Yazdani regarding the RISE Registry as well as MIPS and quality reporting. So as you already know, and MIPS is already upon us, And the data from 2017 will be actually incentivized in 2019.

So why is this important? There are 3,800 nationwide rheumatologists that will have to contribute data. That's really kind of a huge number comparatively. But realistically, the RISE registry, which was supported by ACR but also done by Amgen, has collected over 2,500,000 data points at this time. So while there's a wide variety of data, the important part of this that's really interesting to know is that 15 rheumatologists have already completed all three categories of MIPS, which is great, but the best part about that is that each of them have maximized their incentives for financial reimbursement in 2019.

So that shows us that we do have a long way to go, but at least the RISE Registry is gonna be really effective for all of us. So I hope that you found this information important because I definitely did. And I'll be telling my partners that maybe this is something that we need to look into. So again, if you have any further questions, I'm gonna urge you to go to rheumatology.org for actual Rise Registry information. But check us out on roomnow.com.

We'll be presenting all week at ACR twenty seventeen in San Diego, California. Hi, I'm Doctor. Rachel Tate from Dallas, Texas, coming to you live from ACR twenty seventeen in San Diego, California on day four, the final day. So there's been a lot of really great research, there have been a lot of really great posters this this year, and I'm always interested in some of those kind of fine nuances to things that we already have diagnoses for, but maybe we're looking for a little bit better treatment. So one poster that struck out to me was actually abstract number 2,904 which showed that eighty four percent of Cardiac Sarcoidosis patients who had been refractory to other therapies actually responded to TNFs.

So this is kind of interesting and actually it follows up with something that I was at yesterday with Doctor. Baughman who also discussed some of the nuances in treating sarcoidosis and particularly those patient subsets that are going to be really good at having success with TNF inhibitors. So, in general, what we're looking at, some of the patients that are going to be good responders include those who have chronic advanced pulmonary disease, as well as those patients who have ongoing inflammation, meaning those with continually elevated CRP, which is only about twenty five percent of patients who have sarcoidosis. In addition, those with increased soluble IL-two receptors, positive PET scan changes, as well as TNF alpha G308 polymorphisms, which I know that's something that we don't have clinically available. We do have that available in more academic situations and centers, but also those patients with lupus perineo.

It's a rare form of something that we all study for boards, but those patients are actually good responders to TNF inhibitors, as well as those obviously with neurologic disease and refractory eye disease. So these are some of our subsets of patients that might actually be excellent responders to TNF inhibition. That's something we need to keep in mind when we're examining our cardiac as well as other types of sarcoidosis patients. That's just a little snippet of what you'll hear from us on roomnow.com, presenting live from San Diego, California for ACR seventeen, and I'm Doctor. Rachel Tate.