RheumNow Podcast- The Down Side Of Steroids (1.17.20) Save

It's the 01/17/2020. This is the Room Now podcast, and I'm doctor Jack Cush, executive editor of roomnow.com. This award winning podcast is brought to you by an award winning meeting called wait a second, RheumNow Live. It's coming up 03/13/2020 in Fort Worth, Texas. I think you should think about coming.

We're gonna have a great meeting. Check out our faculty, check out our program. I'm really proud of it. I think you'll be excited. I think the issue is, should you go?

There's a lot of choices, a lot of meetings. Hell, there's too many meetings. And which one should you go to? ACR, CCR, the SODA meeting. RWCS in Maui is a great meeting.

I think RoomNow Live R and L is the best. And I'll tell you why. Many of the meetings are very much the same. You get great speakers telling you, you know, in didactic lectures, you know, how to, this is the list. They explain, they go into detail.

RheumNow Live is more about what if, you know, because patients don't read textbooks and you've got cases that you'd like to ask questions about and you're going be in front of some of the world's leaders on the topics of lupus and psoriatic arthritis and rheumatoid arthritis and auto inflammatory disease and more. I think that the idea here is that our sessions are not just one off lectures from world class experts on a topic, but you may not remember what they said in their one hour lecture. Our program is not just one, but four lectures in a two hour block devoted to those topics, shorter lectures. 25% or more of the time is devoted to Q and A with the audience. It's highly interactive more so than any other meeting that you've ever been to.

And then lastly, there's the fellowship. I know some meetings are just so darn big, you can lose yourself inside the meeting. This meeting is about the ideal number. Studies have shown that if you want to have good interaction between a large number of people getting together, the ideal number is about 150. Well, that's about the size we're going to have in Fort Worth as we did last year in March 2020.

Check it out, roomnow.live, register. I think there's maybe even early bird special going on if that interests you. This week in the news, we've got a lot of interesting reports on pregnancy, vasculitis, lupus, and we're going to talk about gout. Let's talk about pregnancy. An interesting study, a collection of two twenty four pregnancies, one hundred and thirty three women with undifferentiated connective tissue disease, UCTD, otherwise known as MCTD, sometimes called overlap syndrome.

Where do these people fit? How do they get one hundred and thirty three of them who are pregnant together? Well, it's a multi center collection of data. These people had to be ANA positive and had to be under the age of 45, obviously, get pregnant. The outcomes were actually pretty good.

Seventy nine percent live births, stillbirths were just a few less than one percent, and twenty percent miscarriages, which is about the going rate for our patients with autoimmune inflammatory diseases. Three percent had intrauterine growth retardation. And it turns out that those who had stillbirths and miscarriages were more likely to be antiphospholipid and ENA antibody positive. So it's comforting because we see these patients and you need to guide them about what their futures may be. The Canadian medical journal, CMAJ, actually came up with a very interesting report that kind of blows my mind.

And that's the idea of same day discharge for patients undergoing hip or knee arthroplasty. Meaning, you have the surgery and then within four to eight hours of completing the surgery, boom, you're out the door and on the street and fending for yourself. Well, report on a number of studies that have looked at this. They have sort of an overview article says it's feasible. It's certainly possible.

And it's possible because of new surgical techniques, some of the drugs that are used, multimodal anesthesia, making it a little bit easier for patients to recover. And they actually identified the contraindications, age greater than 80. Those with cirrhosis, those with CKD, bleeding disorders should not have same day surgery and out the door. This came to my attention a few months ago, Eric Rittmann circulated an announcement from one of his colleagues in Chicago talking about this and I'd never heard of this. Having a hip replacement and going home the same day, obviously there's a big need for outpatient physical therapy, which is a big part of the success here.

But I think this could be a growing trend and especially with physicians and surgeons wanting to take control of both the care of the patient and the finances of the procedure by doing it in surgical outpatient centers, which they may operate and own, look for this. Doctor. Kevin Winthrop is an infectious disease specialist at Portland at the Oregon Health Science Center. And he's well known to rheumatologists. A lot of work with many leading rheumatologists, including Jeff Curtis and Bing Bingham and Lenny Calabrese.

Kevin is really knowledgeable. He's going to be lecturing at RheumNow live. And he published a paper showing that the incidence of non tuberculous mycobacterial infections has been rising based on claims data. Comparing data from 2008 to 2015, the rate went up by, gee, looks like more than a third, three per one hundred thousand patient years to four point seven per one hundred thousand patient years as far as an incidence and a prevalence also rose almost double during that same rate. As you know, these numbers are actually more common than mycobacterial or mycobacteria TB infections.

So, the atypical mycobacterias are much more common. They're seen more commonly even in normal people, but also in sick populations. And these should be strongly considered in your patients who are on biologics or who develop chronic pulmonary illnesses. A nice study looked at what happens to the fate of patients with breast cancer who have musculoskeletal complaints and are referred to a rheumatology center. One hundred and twenty such patients were referred and evaluated by rheumatologists and a third of them actually had an inflammatory rheumatic disease.

What was most common? Well, it was rheumatoid arthritis at eight percent, Sjogren's at six percent, psoriatic arthritis at five percent. Yes, there were cases of arthralgias related to aromatase inhibitor use and you should look for that. But yes, patients with cancer can come down with arthritis and we may need to see them even if they're not on a checkpoint inhibitor. So, I like these reports about basically the vasculature and bleeding potential.

A 100 patients with GPA were studied and it showed that more than half of them, fifty six percent had elevated D dimer levels. Oh my goodness, does that mean that they were higher risk for clots and strokes and whatnot? Actually, it turns out they do have those events, but it turns out that the D dimer levels were more associated with disease activity and inflammatory markers than they were with the risk of venous thromboembolic events. Overall, out of about one hundred and twenty three patients had a VTE event. However, many of them were not predicted by the presence of D dimers.

So I think that's kind of important in patients that you manage with GPA. My partner, Doctor. Catherine Dow asked me the question this week, if a patient is really sick with sepsis or if they have DIC, do they develop positive antiphospholipid antibodies? I sort of did this for a while. For those of you listening in, I'm scratching my head and looking stupid.

And I didn't know the answer. So I told her where to go. I said, Call special surgery and Doctor. Doric Erkan. He's the guy, he'll know.

And sure enough, he answered right away saying, Yes, it has been reported. We gave you that citation in literature. The particular citation he showed was that patients were critically ill, many of whom had sepsis and bad infections, fifty two percent of them had evidence of a lupus anticoagulant, a prolonged APTT, but they did not have bleeding or thromboembolic complications. So you may have false positive tests in patients with infections. What about in gout?

What's going on in gout? Well, there's a few new things. Horizon put up a press release, so we don't have full data on what's called the MIRROR OL study. OL study, I guess open label. Open label refers to a small number of patients who were treated with peglodecase who also received methotrexate.

And in that study, a complete response was seen in seventy nine percent or eleven out of fourteen patients And that was measured as having, as you would have guessed, a serum uric acid of less than six at month six. These are just top line results. You can read more about it in the press release or what we wrote down in today's report on RheumNow Live. Actually, it's in roomnow.com. Rheumnow Live, that's another thing, right?

There's a nice report that came out about, and I think this is from Alzheimer's Journal of Medicine, about SGL-two inhibitors in diabetes and that being associated with a lower risk of gout attacks. I think this is a report from Sion Kim's group from Beth Israel, but the Brigham. And it's well known that the SGL-two inhibitors, these are patients who have the sodium glucose transport inhibitors that they also inhibit uric acid. And compared to the other drugs that are commonly used, GLP-one inhibitors, GLP-one inhibitors are drugs like Byetta, Victoza, Trulicity, Ozempic. The SGLT2 inhibitors are drugs like Invokana, Farxiga, Jardiance.

Anyway, they did a large claims based study in like two hundred and fifty thousand patients and they showed that the risk of gout was lower when you were on an SGLT2 inhibitor, five events per 1,000 patient years compared to a GLP-one agonist at seven point eight events. So there's an absolute reduction of about thirty six percent to patients taking these drugs. Again, this should be added to your list of drugs that may be helpful in managing patients. But in this case, these people did not have gout. These are people who did not, again, were just followed and incipient or I'm sorry, incident gout occurred far less than people who were taking the right drug to lower their blood glucose.

There's another study on the anifrolumab. We've talked about that a few times. That report finally showed up in New England Journal yesterday. It's the Tulip two study. Last week we talked about, I think the Tulip one study, which was a failed study of anifrolumab in patients with active lupus.

The Tulip two study, which was also presented in ACR, is a positive study showing in three sixty two patients who have active disease measured by a SLETE I2K greater than six at entry. Again, there wasn't a lot of nephritis in that study. But even though they had changed the primary endpoint to a Bicla, both Bicla and SRI4 and CLASI, the skin measurements, were all significantly better. What wasn't significantly better in this trial on anifrolumab compared to placebo was the tender joint count and swollen joint count. The drug was well tolerated, three hundred milligrams given every four weeks.

Side effects were very, very few. Herpes zoster was a little bit higher, seven percent versus one percent. And URIs were more common, about twenty two percent versus ten percent comparing it to placebo. Again, anifrolumab is an alpha interferon inhibitor and they did try to recruit for patients who had the alpha interferon signature and found that in eighty percent of patients. Turns out though, when you did a sub analysis of people who were positive for the type one or alpha interferon signature, they were no more likely to respond.

So, it's quizzical what's going on with anifrolumab and maybe how it works. It worked fabulous in a phase two trial. It failed in the TULIP one phase three trial. It worked in phase trial, a phase three trial of Tulip two. Will it be FDA approved?

Will it go in front of the FDA? Stay tuned. One more report and that's on steroids their use of lupus and are they protective or not? I think we had a report a few weeks ago actually at ACR saying that patients who stay on low dose steroids are less likely to have flares compared to those who you forcibly remove from steroids who are more likely to flare. This particular analysis actually looked at a cohort of patients, 1,700 patients from multiple sites and followed them for two years and really were looking at an endpoint of organ damage.

And organ damage had a specific definition and was found in fifteen percent of the seventeen hundred patients followed. Turns out that the predictors for organ damage were age and physician global and the SLETE I2K measure, but also prednisone. Prednisolone in Europe was an independent risk factor and although it certainly was very used very frequently in like over eighty percent of patients, using prednisone was independently associated with a risk of organ damage suggesting that it's not just a surrogate marker for those with more severe disease or those who are more refractory. When they control for all the factors, prednisone may add to that. Maybe it does so by adding to cardiovascular risk or atherosclerotic or vascular changes, hypertension and whatnot.

So even being on in this study, the median dose in this study was five milligrams a day. So I think we might want to rethink. I have to rethink whether I want to keep my lupus patients on steroids chronically or get them down to as low a dose as possible or even go off. My own experience has been I'm not going to go off. I might try to get to a really low dose, maybe somewhere between two point five and five milligrams.

But this is sort of scary data from, I believe, Annals of Internal Medicine. That's it for this week on the report from RheumNow and this podcast. Be sure to go to the website to check out these citations and more. Go to roomnow.live. Great rheumatologists like you and I go to great meetings like this.

We'll see you in Fort Worth in March.