RheumNow Podcast Downside Of Lupus (2.9.19) Save

Hi. It's the 02/09/2019. This is the RheumNow podcast. I'm doctor Jack Cush, executive editor of rheumnow.com. This week in the news, breast implants are back in the news.

We got a lot of new information about lupus and some surprising associations. And what's the new best placebo out there? Well, it comes from your pain doctor colleague. We'll talk about that more. Our first report is on a cohort study from a university clinic of almost 500 patients showing that twenty four percent met criteria for fibromyalgia.

You know, if you look at any rheumatology clinic, it shows that fibromyalgia is actually one of the major components in most of our clinics. The interesting thing about this study, it looked to show an association between the criteria that are commonly used, and a clinical diagnosis as declared by the clinician, that being identified as an ICD nine ten ICD 10 code of m 79.7. So in this study, twenty four percent met fibromyalgia criteria, but only twenty one percent diagnosed as fibromyalgia by the doctors. In spite of what seems like a pretty good association, the agreement statistic, what's called a kappa value, was only 0.41 was really not so good, suggesting that there's a fair amount of discrepancy. In this study, they showed that physicians failed to diagnose criteria positive patients in a substantial number of patients.

It was like sixty plus patients of the five hundred. And similarly, a wrong diagnosis was given in patients who were criteria negative, suggesting that there still is a fair amount of misdiagnosis or lack of understanding into what fibromyalgia is in the clinic. Or maybe it's a failure of criteria in helping us in the clinic. This merits more research. New information from the CDC, again, on the opioid overdose problem that we have in our country.

In 2017, greater than two thirds of all overdose deaths in The United States were due to opioids, and that the over overdose deaths grew a total of twelve percent, in between 2016 and 2017. That's quite a jump. It's even higher in the elderly, those 65, where it was seventeen point two percent. So while the numbers on opioid, misuse and death, and overdose is really sort of tailing off, it still remains a big public health problem in The United States. An interesting review from the Royal Adelaide Hospital looked at the Association of Silicone Breast Implants in rheumatic disease.

And in their large cohort, over seventeen years of patients that were studied, they found that breast implant patients were more likely to have fibromyalgia and chronic fatigue syndrome when compared to one group scleroderma, but not another group lupus. Now that sort of put this in there because I think this is what we see, what I see in my clinic that patients who have, silicone breast implants don't really have lupus and scleroderma like disease. They tend to have fibromyalgia more than anything else, and I think it's often overlooked to maybe call other things. An interesting study, of patients with the IgG4 related disease syndrome from China looked at one hundred and twenty one patients who are untreated and divided them up into those who had dacroadenitis and sialoadenitis to sort of look at a subset and to see if this subset has any other unique associations. And what they did find that in that subset of patients, they were more likely to have sino nasal involvement, eosinophilia, and higher I g g four levels than those than than those that did not have, dacradenitis and sialoadenitis.

We know we see those in that those features in sarcoid, but it is one of the features that you can see in the IgG4 related disease, syndrome. And I think that we're seeing over time that there are sort of subsets of that syndrome that are playing out. Interestingly, many of you have diagnosed such a patient. I think many of you haven't diagnosed such a patient. The question is, how do you find them?

I think as we better define these subsets, it'll make it easier to make these diagnoses. I recently had a patient who, like for instance, who came to me with retroperitoneal fibrosis, retroperitoneal mass wrapped around the aorta and whatnot, and it turns out it was a gastric cancer, with local spread and not IgG4 related disease. So again, these can be hard cases to manage and evaluate. The antiphospholipid syndrome is has an incidence rate of five per one hundred thousand patients. Looking at a population study, we know what the the triad there is of thrombotic disease, refractory thrombocytopenia, and recurrent fetal loss.

But there are other clinical associations. This very interesting review looked at other diagnoses associated with this, and that included valvular disease, libido reticularis, something called race Racemosa, r a c e m o s a. Never heard of it. Should have looked it up for this report. Didn't.

Tell me what it is. Skin ulcerations with necrotic, ulcerations, glomerulonephritis and thrombotic microangiopathy, of course, AVN and non traumatic fractures are also in that list of disorders that have been associated with the antiphospholipid antibody syndrome. Another report looked at utility of of these indices you get with your complete blood counts. This in this case, they you know, these investigators look at 690 patients, and analyze their SedRay CRPs and RDWs, for the red cell distribution width, showing that RDW, like sed rate and CRP, is associated with inflammatory disorders, had a high correlation in RA and SPA patients, and that the RDW had a 48 to 95% sensitivity and a 66 to 95% specificity for inflammatory disease in their analyses. It should be something you look at.

Obviously, someone who's got a brand new anemia, RDW may mean something else, but it does go up in our patients with inflammatory disorders and can be a useful biomarker. It could be a very cheap biomarker. How about GCA? There's some talk about GCA maybe associated with a risk of cancer, and the French, study group for large vessel vasculitis looked at a small cohort of forty nine GCA patients compared it to a larger control group, three to one match controls, and showed that GCA was not associated with a higher risk of cancer, and that the value is basically the confidence intervals crossed over one suggesting there was not a higher risk. I didn't believe there was, and it's kinda comforting to know that these elderly patients with this aggressive vasculitis do not have a higher risk.

Now what about lupus? I got three reports on lupus in this particular edition of the podcast. Kaiser Permanente studied nearly 2,000 patients with lupus and showed that fifty eight percent of lupus patients were non adherent to the simple drug hydroxychloroquine. That's shocking, but it's actually in line with what's seen in other studies of non compliance, non adherence. You were non compliant if you did not take at least eighty percent of the hydroxychloroquine that was prescribed to you.

So fifty eight, almost sixty percent of patients were non compliant. The factors that were associated with non compliance or non adherence was increasing age and increasing numbers of visits. So people are coming to you a lot, which may be your patients who are sickest or need to see you a lot, are actually maybe less compliant. Not predictive, whereas the doctors involved, the center that they were being treated for with at or other so speaking of factors which have been sometimes related to non adherence noncompliance. Again, this is a major major battle as we take care of patients with chronic, autoimmune and inflammatory disorders.

Another study out of Sweden looks at the association between lupus and chronic lung disorders. So they did not enroll patients who had any sort of lung disease at the outset. They looked at incident and prevalent, lupus in and they found a total of thirty two hundred incident cases. I think there was, like, sixty six hundred prevalent cases cases of lupus in Sweden. And they showed that lung disease was six fold more common, in lupus patients than the controls with an incidence rate of of fourteen per one thousand patient years.

It included a nineteen fold higher risk of interstitial lung disease, which I found a little bit surprising. And you certainly know lupus patients get interstitial lung disease, but it looked like that might be the most common manifestation of lung involvement in lupus patients. The last report on lupus looks at fracture risk in lupus. And this is a population based study shows that the incidence rate for fracture was highest in lupus patients who have nephritis. And I think the study here this is a this is a claim study.

47,000 lupus patients studied four to one against four controls for every one lupus patient, and they showed that the highest rate of fractures was seen in nephritis patients at four point six per one thousand patient years, and that was the highest rate. Lupus patients generally have a twofold higher risk of fractures compared to match comparators. So and when you control for comorbidities and glucocorticoids, it attenuates these risks somewhat, but not not not to a major degree. So, again, you should worry about lupus, and it's not just the steroids that are striving that fracture risk. It can be a number of other factors, especially their nephritis.

And lastly, there's a report out on, compounded pain creams being no more, effective than placebos. You know, these compounded pain creams are often advertised or, prescribed by doctors who work in pain clinics for either neuropathic pain where they use concoctions of ketamine, gabapentin, clonidine, lidocaine. For nociceptive pain where they use ketoprofen, baclofen, cyclobenzaprine, lidocaine, or mixed pain, you know, all of those in, you know, in various combinations. The interesting thing is that these pennies to sense drugs are mixed together and sold at a premium price, a knockout price like, you know, you know, thousands of dollars a bottle. And it used to be that they were being paid for by managed care.

I find that very few managed care companies are paying for these, and patients sometimes are paying for them cash out of pocket. And they've gone into disfavor in many places, in many corners. And, you know, the FDA is looking at this. The FDA is looking at the use of these kind of concoctions and whether it's legitimate or not. But But in this particular study of almost 400 patients, they showed that in their primary outcome of being, pain reduction, that a significant response was seen with a pain cream in thirty six percent of patients, and it was twenty eight percent in those on placebo.

And again, that was not significant. So I haven't used these. I strongly dissuade patients from using these. There are either over the counter preparations like capsaicin or prescription pain creams like lidocaine, and one that eludes me right now that are out there that you can certainly use, like, oh, the diclofenac creams are are and they can be expensive too, but certainly not expensive as these mixed compounded pain creams. Anyway, that's it for this week on the RheumNow podcast.

Go to rheumnow.live to check out our meeting. You can go to the website to get these links and read more about these particular reports. We'll talk to you next week on RheumNow podcasts.