RheumNow Podcast Can RA Be Prevented %2812.7.18%29 Save

It's 12/07/2018. This is the RheumNow podcast brought to you by RheumNow Live. I'm Doctor. Jack Cush, executive editor of roomnow.com. I have three questions for you to begin this program.

What makes back pain worse? No, really. What makes back pain really worse? Second, should you treat patients who have preclinical RA, you know, aches and pains and a positive rheumatoid factor or CCP with or without a family history? How should that be managed?

And lastly, what is your best recommendation for weight loss in your patients who really need it? This and more on this edition of the Room Now podcast. We're going to start out with a study from Johns Hopkins that looked at side effects associated with immune checkpoint inhibitors. Bing Bingham and Capelli and colleagues over at Johns Hopkins have been studying this for a while and they have a study of twenty seven patients who've developed inflammatory arthritis associated with the immune checkpoint inhibitors. Turns out that all of them were largely of Northern European ancestry.

And they showed a higher rate of the at least one copy of the shared epitope compared to controls. It was similar in the risk of having a shared epitope with RA alone. But when I looked at other patients who didn't have this, the shared epitope seemed to predict the onset of inflammatory arthritis. Again, these side effects are seen with the immune checkpoint inhibitors seem to be quite common and musculoskeletal side effects seem to be quite common. A recent lecture I did with Artie Cavanaugh, we asked the audience how many of you have seen this?

More than half the audience has seen this phenomenon of immune related adverse events associated with checkpoint inhibitors. And again, what has been shown by a number of people including Len Calabrese and Bing Bingham and others is that patients who have inflammatory arthritis or an autoimmune condition tend to worsen when they go on immune checkpoint inhibitors. So you need to know about the syndrome, you need to have a strategy for managing the syndrome. A retrospective study of patients who were obese, greater than a BMI greater than thirty five, did a comparative analysis of those who received different forms of bariatric study. They compared the RheumWhy gastric bypass to the gastric sleeve, to gastric banding.

And it turns out the RUIN Y actually had the greatest degree of success in long term weight loss compared to gastric bypass, which was better than gastric banding. However, the RUIN Y had a higher degree of adverse events especially in the first thirty days. Therefore, the data suggests that, that the gastric sleeve is probably the most advantageous procedure at the current time. Gastric banding has a lot of problems and a lower success rate. The gastric sleeve is actually a fairly invasive procedure but has a fairly good success rate.

I looked into this, you know, I'm a little chubby, and looked into this and everyone I talked to, everything I read says again, gastric, sleeve is probably the preferred procedure here. A nice review of experts, developed interdisciplinary, I'm not sure where the English went on that one, guidelines for treating uveitis in children with JIA. As you know, this is not an uncommon side effect, especially in those who have oligoarticular, postarticular disease, those who are ANA positive. And again, those people, they have a good prognosis for their joints and a guarded prognosis for their eyes. So you need a strategy for managing their eye disease.

These guidelines which are largely expert based and there isn't a lot of comparative studies say that number one, topical steroids is your first choice. If that's not effective, they should be started on a systemic drug like methotrexate. If that's not effective, then a TNF inhibitor, presumably an antibody based TNF inhibitor, then after that systemic steroids, and then after that other, non TNF biologics including tocilizumab, abatacid, and rituximab. Good to have these guidelines be better to actually have comparative trials based on some data and guidelines based on, you know, high quality data. Right now we're best with expert opinion.

A nice study looked at patients with RA, PSA, and psoriatic arthritis, specifically looking at the risk of patients developing multiple myeloma, a cancer when you take a biologic for any one of those conditions. So this is a fairly large study compared and fifty six thousand patients, and found two eighty seven patients, who developed multiple myeloma compared them to a batch control group and showed that the risk of multiple myeloma was not any higher when patients were on a biologic DMARDs or NSAIDs. However, in an interesting analysis, sub analysis, they showed that patients who are only treated with DMARDs tended to have a higher risk of multiple myeloma compared to those treated with just a biologic, meaning that biologics may have had some protective benefit. This goes along with what I've been saying all along, treat, let someone else treat the cancer, you treat the disease. Biologics do not generally cause cancer, they do not cause lymphoma, Although cancer risk, all the lymphoma risk is related to the disease and related to inflammation.

And there's very little evidence that argues against us, a whole lot of evidence that's argues in favor of that. Depression, is a big problem. Depression and back pain is a much bigger problem. Well, a very interesting analysis of seventy three thousand patients of whom, six thousand seven hundred had back pain. And they looked at that subset of patients who had Medicare patients who had back pain and found it was a subset of them who had depression.

The annual healthcare costs for those with depression was substantially higher in patients with back pain and depression, thirteen thousand versus seven thousand four hundred. There's a lot of data coming out lately that, the coexistence of depression on the background of arthritis or musculoskeletal conditions clearly worsens both the outcome and in this case, the cost of care, suggesting that we should be paying much greater attention to depression, being much more aggressive in depression management. If you can't do it, let someone who does depression manage it well. I found a nice study that compared the outcomes of lupus patients treated in either a lupus clinic or a general rheumatology clinic. This comes from Rush University Medical Center where they had a prospective enrollment of one hundred and fifty patients with lupus, half of whom went into rheumatology clinic and other half went into a lupus specific clinic that had some guidelines on management.

Again, when it comes to quality measures, it turns out those treated in the lupus clinic had a much better outcome. Better chance of getting sunscreen counseling, ninety nine percent versus eighty four percent. Anti phospholipid testing, seventy one versus thirty seven percent, pneumococcal vaccination, eighty four versus forty eight percent, bone mineral density testing, ninety four versus fifty four, drug counseling, ninety two versus eighty percent, steroid sparing agent use, a hundred percent versus eighty two percent, ACE inhibitor use, ninety four percent versus fifty eight percent. Again, I think it's not, surprising that they would do better at these outcome measures, but you know what, they're not looking at lupus outcome measures really specifically, they're looking at a lot of general healthcare outcomes that are very important that we should be doing, especially in our lupus patients. And then they're looking at some things related specifically to lupus.

So this says a few things. One, that maybe those of you who don't have the opportunity to have a lupus clinic need to get a checklist for patients with special conditions and deliver specialty care for them and go through this checklist like sunscreen and APL testing, vaccination, BMDs, use of steroid sparing agents, inhibitor, etcetera. So the idea here is, again, it would be great to have a lupus clinic. We did at Southwestern when I was there during my young, years and as a faculty member, Artie Cavanaugh ran that with Peter Lipsky and they did really did a fabulous job. And then they turned them back over to the rheumatologist and I think we did a good job too, but, probably not as good as they did.

You know, there's this big issue out there about preclinical RA and whether or not those patients should be tested. We're generally talking about patients here, the definition is someone who's got a serologic, positive marker, ACPA or rheumatoid factor or, one of the other rheumatoid associated autoantibodies, along with a symptom, usually arthralgia, and then either a first degree relative or, a high CRP or acute phase reactant being present. You know, we presented also a year and a half ago the results of the Prairie study, and now it finally appears in print. This was in the Annals Rheumatic Disease authored by Paul Peter Tack and others, and eighty one patients were prospectively studied. They had preclinical RA meaning they were seropositive.

They had to have either an elevated CRP or ESR or a swollen joint. Turns out that many people were identified in affair and many of them actually had a family history of having rheumatoid arthritis. And they basically showed that, the risk of patients were treated with either placebo infusion or a single thousand milligram infusion of rituximab, and then followed prospectively for three years. And looking at one year, twelve months later, using rituximab reduced the risk of developing rheumatoid arthritis by as much as fifty five percent. However, even though the hazard ratio is 0.45, it crossed one in confidence intervals suggesting that it was not significant.

The numbers lean that way, that maybe it is significant. So looking out at thirty months, forty percent of patients on the placebo group developed RA and did so in a median of eleven point five months. However, those who did develop RA and the rituximab group, it took sixteen point five months and it happened in a lower percentage of thirty four percent. There are a number of trials going on in this area. There's one I think in hydroxychloroquine, there's one with apatacep, and we're awaiting those results.

But the PRAYER study was the first one. You could say that these results were not significant because you didn't really truly treat them with rituximab. You gave one single infusion and that was it. There were no other differences in therapy between the group. What if you continue to treat them with either two full infusions and done every six months or every year, would it have changed the outcome?

Who knows, but we need better studies with more complete courses of therapy. Many rheumatologists are sort of guilted into using hydroxychloroquine, few have experimented with methotrexate. I can't recommend either of those. I think we need to see the data on better management of preclinical RA. But preclinical RA will lead to RA in many people, and that's a that's certainly a big concern.

Also published this week on RheumNow was the new ACR, NPF guidelines on the mannen Hurst psoriatic arthritis. These are controversial. They came out and basically said that, for treatment naive, active PSA usually early in the disease, they recommend a TNF inhibitor as the first therapy over oral DMARR therapy and that includes everything but the JAK inhibitors. This is surprising because the recent SEEM study done with methotrexate versus a TNF inhibitor versus both showed that methotrexate and the TNF inhibitor did just as well. There's a lack of really good data about methotrexate use or other early DMARD use, in patients with psoriatic arthritis.

There's a lot of data about the use of biologics, mainly TNF inhibitors in psoriatic arthritis, and that's why this happened. Oral small molecules were recommended when you couldn't use a TNF inhibitor, and the use of other agents like the IL-seventeen agents could be used after a TNF biologic or when the other drugs were otherwise contraindicated. So a very controversial set of guidelines, will they be updated? It remains to be seen when people start to see the results of the SEEM study in, practice. So, I did a recent survey of rheumatologists, the RheumNow rheumatologists, and asked a number of questions.

One question was, what determines whether or not you go to a medical meeting? And the number one answer was actually the site or venue, I found that surprising. The second was faculty, third topics, fourth time away from practice, and fifth cost. I wanna remind you about RheumNow Live, it's being held in beautiful downtown Fort Worth. Never been to Fort Worth, it's unlike any other Texas you've probably been to.

It's like those cities that are a little bit distinctive, New Orleans and San Francisco and Nashville and I think Fort Worth fits in there nicely. It's gonna be held at the beautiful downtown Worthington Hotel, is within walking distance of everything. There's like a million things to see in Fort Worth. The faculty I can't fully reveal to you now, Arty and I, are gonna be faculty. Some of the faculty are gonna be fabulous.

Actually, most of the faculty are gonna be really outstanding, and we're waiting for confirmation on them and their speakers, their talks. The talks that we're giving, just a few, catastrophic lupus, GCA, GPA, vasculitis mimics, the shoulder exam, the development of JAK inhibitors, and seronegative RA. That's a lecture I'll be giving. What's great about this meeting is time away from practice is basically nil. You can fly in on Friday morning, you can attend the meetings which starts Friday afternoon, and then be home Sunday afternoon after the meeting ends.

This meeting is really quite affordable. We have a discount going on now for the holidays where you can register if you're a rheumatologist or a fellow, 75 or a $145, it's amazingly low. And If you register now and book your hotel, you can do this for a fraction of what you would do any other meeting for. And this is going to be an earth shattering groundbreaking meeting for reasons I'll tell you in future podcasts. That's it for this week on the podcast report.

You can go to the website and you can click on these links and learn more about these citations, and be sure to tell your friends to tune into RheumNow. Be sure to bring a friend with you to RheumNow Live in Fort Worth in March. We'll see you then.