RheumNow Podcast – ACR 2020 is Coming to Town (10.30.20) Save

10/30/2020. This is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. You know, tomorrow's Halloween.

Last year, we did a podcast on Halloween. I wore a mask the whole way. No, this isn't a mask. Let's start out with an introduction to RheumNow. RheumNow is our digital platform dedicated to the field of rheumatology.

It's written by rheumatologists for rheumatologists. We provide daily news, insights, perspectives for you and for the field. If you scan our daily email, it comes to you Monday through Friday, it'll take you fifteen seconds, and you'll have a grasp of what's going on in the world of rheumatology. We only provide stuff that I deem and we deem to be important to you. We encourage you to join the conversation by signing in on our website and providing commentary, participating in our surveys, following us on social media, enjoying our videos and podcasts.

Please let me know when you have a suggestion, a cool new citation that I we should feature, a gripe, new idea, even a novel case. That's why we have the backtalk feature on our email and on our website where you can go and record a message to me. As you know, ACR twenty twenty, the virtual meeting is coming up. We're but a week away from it, and, I want you to know about some of the bonus stuff that we're gonna be doing on RheumNow. We have a new feature called ACR IQ, daily quiz where you can figure out whether you're staying up on what's happening at ACR.

We have a new feature called ACR Topic Chat. It's sort of like our bulletin board where if you're interested in psoriatic arthritis, that's where people are gonna be talking about psoriatic arthritis. We are going to again publish our ACR Playbook this year. It's the virtual playbook. Sign in, download, check it out.

It's a new way to learn in a virtual environment. We're gonna have pre meeting coverage starting next Monday. We're gonna have post meeting coverage after the following Monday. So this is gonna go on for months, but we're really gonna be intense about ACR coverage for the next two weeks. We're going to daily put up our day one, day two reports.

We're gonna have ACR best tweets. We're gonna develop top five lists of the day. We're gonna have top 10 lists at the end of the meeting. And then we're gonna have this new thing called perspective videos where you're gonna have KOLs, key opinion leaders, giving you their perspective on what's happening in the field and how developments at ACR might be changing that. And then we're gonna end up with two new things, evening productions, Saturday night.

Next Saturday night, it's going to be the mid meeting recap meeting where we're gonna have a a webinar, and we're going to hear from some of our faculty and our topic editors on what's happening, either what's already happened or what's going to happen. And then on Monday night, the last day of the meeting, Artie Cavanaugh and I are going to do again our Rheumatology Roundup. We're famous for it. Not sure why, but we are. Hope you're going to enjoy that.

So let's get into this week's podcast and bevy of news. First comes a meta analysis of seven large studies, cohort studies, 34,000 biologic users, a 135,000 non biologic users who took a biologic for either RA, psoriasis, or IBD, and they looked at the risk for melanoma. As you know, this is an ongoing debate. The early observational data, retrospective data suggested maybe there's an increased risk with TNF inhibitors. Then there was this very large, was it nine registries, 11 countries, 11 registries, nine countries, showing that biologics were not associated with an increased risk of new onset of, invasive melanoma.

It didn't address the issue of recurrence of malignant melanoma. And this particular study, they're looking again at melanoma risk. They don't really distinguish between, whether it's invasive or not. They found no significant increase in melanoma risk if you were on an individual biologic or, all of them together, and this was held true for RA, IBD, and psoriasis. For instance, the RA data, the relative risk was 1.2, but the confidence intervals overlapped one from 0.83 to 1.74 saying it's not significant.

They said, if we had more patients, could figure it out. My goodness, you've got almost 200,000 patients on biologics here. I think, it's clear to me, you can make up your own mind about that data. Speaking again of large data, an international psoriasis registry looked at the risk of hospitalization if you had psoriasis and you got COVID. And they divided up the risk based on whether you're taking a biologic or whether you're taking a non biologic.

And when you compared biologic takers to non biologic takers, guess what? You had half the risk of developing hospitalization, sixteen percent versus thirty three percent. Hence, if you were on a non biologic, you had almost a threefold increased risk of being hospitalized. So again, this sort of mirrors the data that we've seen in our, other rheumatology patients where good disease control and biologics seem to be efficacious. If you're not well controlled, that could be a risk factor and maybe it's a little bit more likely taking conventional DMARD therapies.

Speaking of new therapies and new uses, the JAK inhibitors, as you know, are really making a big, splash in the in the derm world. I mentioned last week or two weeks ago, they could take the become the standard of care in the derm world, but, a new report, uncontrolled, small cohort looks at a pretty rare disease, juvenile dermatomyositis, JDM, twenty five patients with refractory disease who were treated with a JAK inhibitor, actually two of them, either tofacitinib or ruxolitinib, a drug that's used for, myelodysplasia. All of them improve their rashes, two thirds of them went into complete remission on or resolution of the rash on the JAK inhibitor, forty percent improve their muscle strength, twenty eight percent discontinued, their their steroid use, kind of impressive. Again, I believe you'll see more drug development in this area, as you know, eczema and atopic dermatitis is another hot area that we've treated on that this week and in the past. An interesting population based study from New York looked at what happens to patients undergoing either knee or hip replacements, one hundred and sixty eight thousand and three hundred and eight thousand patients respectively who underwent, joint replacement surgery for osteoarthritis.

And what they showed was that for those who had joint replacement, there was a significant decrease in the subsequent falls of those OA patients compared to those who didn't have surgery. So it was basically about a thirty four to forty four percent reduction in falls, and you have to assume that, you know, patients who didn't have surgery had a worse course, stayed weaker, were more unstable in their gait, and then joint replacement was the reason for this reduction. Again, the risk of falls do go up significantly with age. Again, if you were in the 70 to 79 year old age group, it was a fourfold increased risk. If you're over 80 years, it was a five and a half fold increased risk.

And I think, you know, the point is that because you're old doesn't mean that you shouldn't get, joint replacement surgery. In fact, that may be the best thing to do. I always tell my patients, Bob Hope at age 91 had a hip replacement and lived another nine years or so. And again, I think he had a lot of other medical problems at the time, but I don't think his hips were the final problems in his life. So, speaking of, COVID, was I talking about COVID?

Well, tell me, show me a podcast where I don't talk about COVID. Building on some past reports, there's a new preprint that's out this week showing that, COVID-nineteen patients have a higher, incidence of autoantibodies, specifically, ANAs, rheumatoid factor, anti RNP, anticentromere, antiphospholipid, and ANCA, c ANCAs. Again, a small number in each of these, and and again, this is a preprint and whatnot, but it does go towards what we talked about before that there's a there seems to be this incidence of, antiphospholipid antibodies and lupus anticoagulant, which does sort of jive with the problem of bleeding, that is seen and a complication of bleeding and thrombosis that's seen in patients with COVID, which is why many patients really need to be on anticoagulation if they're hospitalized with the coronavirus. So during the week, had a case of palindromic rheumatism. I found a really cool citation from Journal of Rheumatology in 1999.

It's in it's in the show notes here. A hundred and twenty seven patients who met criteria, the most affected joints with palindromic rheumatism were wrist, knee, and MCPs. It turns out pretty consistent number in many, many studies, about a third of palindromic rheumatism patients will develop a connective tissue disease and almost all of those are rheumatoid arthritis. That risk is driven by having, either RF or CCP antibodies, where there's a threefold higher risk of developing RA if you have palindromachromatism and you're seropositive. Other risk factors for progression to RA would include hand involvement, PIPs, and also wrist, and also being female, each of those being about a two to two and a half fold increased risk.

Palindromic rheumatism gets labeled as a lot of different things. Many of them get treated symptomatically, Some of them will actually require DMARDs. Maybe you can lean towards DMARDs in patients who are meeting these particular risk criteria. A review was published this past week about the safety of Nintedinib or Nintendo as I when I wanna act stupid, which I have to refrain from. Nintedinib is a new drug that's only new drug approved for scleroderma interstitial lung disease in their, published study, was England Journal study, five seventy six patients who were given entetinib, one hundred and fifty milligrams BID or placebo for a year.

In that protocol, if, you did not tolerate the drug, you could lower the dose to one hundred BID because of adverse events. As far as safety goes, we know the drug worked. There was an advantage to taking, nintedinib, but there is a significant, risk of side effects with this drug, mainly diarrhea and GI. Seventy six percent of people on ententenib had diarrhea, about seven percent of those had to stop, ten percent, compared to placebo where it happened to thirty two percent and only zero point three percent had to stop. Dose reduction occurred in almost half of the intended patients, but only twelve percent of those on placebo.

And of those that did have a dose reduction, a fair number of them actually had to stop the drug. Sixteen percent or one in three of the of the forty eight percent, sixteen percent had to stop the drug. So again, the drug is a is a nice new advantage, but you're gonna have to manage the GI toxicity if you're going to use that. So I like to tweet about things that are clinical questions, ones that you see in the clinic. Another question came up, I went to the package insert, it's where all the good data is and found stuff that you did not know.

Did you know that there are warnings against the use of JAK inhibitors in patients with severe liver disease. You know, usually that's higher than fivefold elevations of LFTs. But, again, if you have severe liver problems, you're not supposed to use any of the three JAK inhibitors. Not TOFA, not Bari, not, UPA. No.

But they all do say that you can use it in mild liver disease. So because you have a liver enzyme elevation within two or less than three fold elevated above the upper limit of normals. That's probably stable. Only the, tofacitinib says what to do with moderate disease, and they say use a lower dose of five milligrams BID as opposed to the ten BID or eleven BID. Note that these drugs have not been studied in patients with hep c or hep b.

We're waiting to see the results of that. So, two other news are three other news articles I thought were important that you should know about, abatacep in early systemic sclerosis. This was published recently. It actually is a extension of an earlier phase two trial that might have been mentioned here, don't know, it's probably a year ago. Again, is called the ATTEST trial.

And in this trial was a twelve month double blind randomized trial of abatacept versus placebo, and they use a number of outcomes, but it met its primary endpoint improvement in skin score as measured by modified Rodnan skin score. So the ABBA group dropped their, Rodnan skin scores by minus 6.6, whereas the placebo only dropped to 3.7, advantage ABBA. And that was at month 12. After month 12, patients were offered the ability to roll over, if you're on placebo to ABBA and continue with another six months open label, analysis. All in all, the original trial had 88 patients, about sixty four patients continued in the additional six months of open label, where everybody's on ABBA.

For another six months at eight month 18, those originally on ABBA and continuing on ABBA, now they had a minus 9.8 reduction in their modified Ronin Skin score. I don't know about you. I actually do these modified Ronin Skin scores. If you're above 12, you have a lot. So these are people with pretty severe disease with pretty big drops in a fairly short amount of time.

It I think it's kinda quite encouraging. The placebo patients who crossed over to ABBA, are minus 3.7, did some catch up, they got to minus 6.3 at eighteen months. And again, no new changes here as far as, adverse events over time in these patients. I think the data is, it's only phase two, and phase two scleroderma always looks kinda good for a number of different drugs and kinda peters out when it gets into phase three. We need another study, need a large phase three, too large phase three, we need another drug as Huey Lewis said, for our patients with scleroderma.

I had a nice review, a full read review that you can see immune mediated necrotizing myopathy, very nice review, basically outlines the fact that necrotizing myopathy is largely seen in patients with anti SRP signal recognition particle antibodies, or those with HMG Co Reductase antibodies, HMGCR antibodies, which were heretofore associated with statin related myopathy and only a very small percentage of patients with HMGCR antibodies, related to statins will develop necrotizing myositis. But if you look at all patients who are found to have inflammatory necrotizing myositis, you should be checking for SRP and HMGCR. Turns out that those with SRPs are at a higher risk for myocarditis and those with HMGCR, higher risk of cancer. These are difficult patients, you know, they have rapid progression, they, really are difficult to treat, they need to be identified early on. You know, I previously not very big on doing a lot of myositis specific antibody testing, but I think this is a these two in this situation makes a lot of sense.

I think the use of the newer ones, TIFF-one gamma, NXP-two, we talked about an MDA-five are also indicated in certain instances. But again, this is a nice review that you should look at. Lastly, congratulations to rheumatologists who are doing telemedicine. I think it's a big, thing that you've done during the pandemic. And in, arthritis care and, research, a new report that just came out about a 122 RA patients in Alaska who were treated with telemedicine or routine face to face care.

And it basically showed in these RA patients, was no difference in the outcomes and care of those who were treated by telemedicine. This is a study from Alaska that was started before COVID, so it wasn't really influenced by COVID and the results are not, are therefore not COVID results. What they showed was again, rapid three scores and quality of life was the same with improvements in both groups. If there was a difference that the rheumatologist visit was more likely with the telemedicine visit and less likely with the in person visit where they might be seen by a physician extender, who I get in trouble when I say that, an advanced practice provider, either a PA or a nurse practitioner. And, actually those who were seen by telemedicine were less likely to have disease activity measures collected.

That's not necessary, You can collect these these activity measures all across. Bottom line is though, it's really good news that telemedicine seems to be effective in RA care, and I would thoroughly endorse its care going forward in rheumatology. I'm spending about half my time doing telemedicine and half my time doing face to face. That's it for this week. Go to the website, check out these citations and more.

Check-in with us next week at ACR. You give us two two hours, we'll give you the meeting to carry yourselves. Oh, back talk, we don't have enough time. We'll talk about back talk next time. Send your questions in.