RheumNow Podcast Eat Your Veggies (4.19.19) Save
RheumNow Podcast Eat Your Veggies (4.19.19) by Dr. Cush
Transcription
It's the 04/19/2019. This is the RheumNow podcast brought to you by roomnow.live. I'm doctor Jack Cush, executive editor of roomnow.com. This week, we're gonna talk about time. A famous man once said that time wounds all heals.
Did I get that right? I did. Specifically, we're going talk about time to flare when withdrawing DMARR therapy or the timing of steroid use when doing a temporal artery biopsy. Or how about the timing of cortisone injections when doing surgery on a joint that you're injecting. This and more in this edition of the RheumNow podcast.
We're gonna start with, a tweet that I put out just yesterday, I believe, about NXP two antibodies. I find these fascinating. Number one, they're coming across our desk. If you order a myositis panel, a lot of the companies that are doing myositis antibody bottles, which used to be, you know, PL7, PL12, MI2, SRP, JO1, EJ, OJ, those things. But now they're adding in without really are asking for TIFF1 gamma antibodies and NXP two antibodies.
Very interesting. But I looked this up just again recently because I have a patient with dermatomyositis and extensive calcinosis cutis, and she's has, lo and behold, an NXP antibody. Now NXP-two and the TIF-one gamma antibodies are two new antibodies associated with, cancer, especially in adults. They can be seen in kids, but when seen in adults, there's a they seem to be associated with cancer. I believe eighty five percent of patients who have cancer and dermatomyositis will have NXP two or TIF one antibodies.
This along with the MDA five antibodies is a real new constellation to autoantibody profiling. But I want to talk about NXP-two. Again, it can be seen in kids, be seen in adults, can be associated with more severe myositis disease and very refractory myositis disease. But I learned just this week that one of the cutaneous manifestations seen with NXP-two is calcinosis and it can be widespread, it can be difficult to manage, it might well be the sole manifestation of disease. So that's something to look forward.
A recent article in Rheumatology, March 16, actually reviews this to some extent. Another interesting report was about ultrasound and identifying and these are findings by ultrasound. Not surprisingly, they looked at patients with psoriatic arthritis and psoriasis and use fibromyalgia patients. I thought that was going to be a control, but wait, no, they found an thesesial inflammation in sixty six percent of the PSA patients and oh, no. No.
No. Let me go back. Using ultrasound, everybody had antiscezial evidence of of involvement. Ninety plus percent in PSA and in psoriasis. Fibromyalgia was seventy five percent.
What? If you looked at just clinical manifestation of enthesitis, meaning you press on it and it hurts, much more prevalent in fibromyalgia, ninety two percent versus two thirds of patients with psoriasis or psoriatic arthritis. My point is, shouldn't emphesitis by ultrasound be more specific for the spondyloarthritis kind of diseases like psoriatic disease? Why is fibromyalgia showing up so positive? To me this looks like, AM stiffness.
We all love AM stiffness in rheumatology. We think it's the fabulous inflammatory marker that it is until you get to fibromyalgia patients when more than half of them have significant AM stiffness, and there goes your whole association with inflammatory disease. Anyway, I don't do a lot of ultrasound, but seeing this data about ultrasound, enthesitis and FM, one of you ultrasound mavens needs to explain to me and then I'll come back and tell the rest of the world why I shouldn't be so hard on ultrasound, as a tool in fibromyalgia. An interesting study was published by David Felsen and his colleagues looking at over eighty patients with medial knee OA and the efficacy of lateral wedge sole inserts. As you know, it's often used.
There's not a lot of data about its use. They looked at about 80 something patients and then did a pre screening test to show that that if you actually did use a lateral wedge insert that it might have enough corrective action to be beneficial in unloading OA of the knee, especially in the medial compartment. So in their study of sixty three preselected patients, they showed a significant reduction in, pain, for those that were taking or using the lateral wedge, insoles compared to those that were using a neutral sole. The problem is that the difference was really small 0.7 on a zero to 10 scale. So while significant numerically, not significant clinically, suggesting that there's probably only a limited number of patients who really will respond to lateral wedge insoles.
I can vouch for this. I actually had severe bilateral medial knee OA required knee replacement after about twenty years of almost bone on bone. I use lateral wedge sole inserts. I don't know why I use them, but I use them thinking it might be helping. I don't know that it really helped a lot.
It wasn't really clinically apparent to me. So I just went from research to my own anecdotal experience. This must be a good podcast. The Tara study looked at RA patients, almost 200 of them. They were in remission.
They were on a combination of a TNF inhibitor and a DMARD or actually a biologic and a DMARD. And then they withdrew the either the biologic or the conventional DMARD and looked at flare rates a year later. At one year, flare rates were similar between those who had a DMARD weaning of thirty three percent versus those who had a biologic weaning of forty three percent, suggesting maybe more benefit with the biologic, but these results were not significant. The authors concluded it doesn't matter, and maybe therefore you should try to withdraw the biologic being that it's like a billion times more expensive. Interesting study.
You know, I don't know why we're still doing weaning studies and withdrawal studies and cessation studies. This seems like to be a bit nonsensical because we've done this research already for the last almost ten years, really six years. The ACR guidelines are very, very clear that there's a risk when you taper. So you probably shouldn't taper. The guidelines say that, that if the patient has low disease activity, to taper would be a bad idea because everybody flares or too many are going to flare.
It also says that if you're in remission, you could probably taper some drugs but not stop any drugs, meaning you could probably taper the DMARD and continue the biologic. The study, the Tara study says maybe these are opposite, but you can't go off therapy because there are consequences to that. Patients are high flare rate and there's radiographic progression that is seen over time. Of course, the real issue on tapering is that patients want to do this anyway. So you need to be armed with the data about how successful this is gonna be.
Generally, data that you should be giving is quite negative. But if patients can get away with it, then congratulations, but it's only going to be a minority. The new drug, Romexizumab, say that three times fast, was approved by the FDA just recently. Its trade name is called Evenity. The drug, the anti sclerosin inhibitor was developed by Amgen and UCB.
After a bit of a rocky road and a complete response letter, the drug was approved. The price was announced this week. It's gonna be 1,800 a month or about $22,000 a year. Don't worry, it's not available yet, but it will be available later in the year. It is approved for only postmenopausal, osteoporosis patients who are at high risk for fracture.
The cost that has been quoted by Amgen is said to be 34 to 74% lower than as seen with TYMLOS and Forteo, the other bone building agents that are out there. Peripheral nervous system involvement and lupus, say, oh, I can't remember. Everybody's got numbness. I never know what that's all about. And is it worth pursuing?
Well, it turns out in a in a review of the literature, it's only seen in less than seven percent of patients with lupus. Most of those, actually not most of them, a third of them was, sensory polyneuropathy, a third were cranial neuropathies, and then as a smattering of other in very few cases of mononeuritis. The risk of peripheral neuropathy was seen with advancing age, advancing lupus activity and damage. So again, it's not that common, you're not probably going to see this in young lupus patients, hot new diagnosed lupus patients. It can be seen but it's pretty uncommon.
An interesting report comes from the VA study was reported in arthritis care and research, ACNR Care and Rheumatoid, Arthritis Care and Research, the sister journal to arthritis and rheumatism. Wait, now it's called Arthritis and Rheumatology. Why did they keep changing the names of these journals? Anyway, the VA study looked at temporal artery biopsy in GCA patients. The numbers here are staggering.
Over 3,000 temporal artery biopsies done, ten percent of them were positive. And they looked at the factors that were involved in yielding a positive result. They showed that the, you should everybody should know this, but I think the data that they came up with reinforces what should be known is that is the length of the biopsy that's most important. In fact, the length must be at least three centimeters to yield the greatest results. And by having a three centimeter or larger biopsy, you have a fifty eight percent increase odds of having a positive result.
Doing bilateral biopsies, generally, I don't do those, but if you're hell bent on making a diagnosis, diagnosis doing two rather than one, increases the odds of a positive result by eighty three percent. Age greater than 71 years is also a predictive factor. The interesting thing about this study and why it made the highlight reel here is that prednisone use up to forty two days prior to the biopsy did not influence biopsy results. So there's a little bit of conflict out there on this, but I don't think you should avoid a biopsy if someone has recently been started on steroids, which you must do. If you really think they have GCA, they could lose their eyesight, start them on 680mg of prednisone and get the biopsy ASAP.
Risk of gout. We know the risk factors for gout, you know, shellfish, alcohol, you know, hanging around in hookah bars. That's my own opinion. I've never been in a hookah bar, truth be told. So but we do know that there are some things that are protective too.
An interesting study from two large Chinese dietary studies shows that those who are eating a vegetarian plant based diet actually have a significantly lower risk up to a sixty percent lower risk of actually developing gout in the future. So avoid the alcohol, skip the sake, go for the vegetables, you'll do better in the long run. A nice article came out in the surgical or the surgical literature looking at the timing of shoulder corticosteroid injections in patients who ultimately underwent rotator cuff surgery. This is a very large cohort like thousands and thousands of patients and they compared those who had had a prior shoulder injection in the year prior to surgery versus those who never had. And they showed that having a shoulder steroid injection did not, adversely affect the outcomes and success of surgery or the complications thereof.
However, if that steroid shoulder injection was done within thirty days of the surgical procedure, guess what? Bad news, Charlie. The rates which were less than point eight percent now went up to one point three percent for those who had a recent injection. Therefore increasing the odds to one point seven or seventy percent increase if you had a recent injection. Risk factors for infection included male, obesity, smoking, diabetes, and again this perioperative steroid injection.
Our last report concerns risk factors with scleroderma and systemic sclerosis. They had two thirds of their patients had localized disease, one third progressive disease. In this particular study, they showed that there was an increased risk of mortality. Standard mortality rates were increased in scleroderma patients. That's not surprising.
Fairly low and the SMR was 5.73 in this particular study. A meta analysis of all the literature out there looked at this showed that the SMR was 3.45, suggesting it's higher. The one year, two year mortality rates are fairly low, but the five year mortality rate is about, fourteen percent. The ten year mortality rate is about twenty eight percent, in scleroderma and so that's kind of shocking. Reduced survival, elderly or over age 60, diffuse systemic sclerosis, scleroderma renal crisis, dyspnea, six minute walk time being prolonged, forced vital capacity less than 70%, DLCO less than 70%, pulmonary hypertension, telangiectasia, valvular heart disease, malignant malignancy anemia, and a CRP that's abnormal.
Another review of the literature showed pretty much the same profile, mortality being linked also to SCL 70 antibodies, but not linked to antisentromere antibodies, maybe a little higher on those with cardiac renal involvement, interstitial lung disease, pulmonary hypertension has been as has been stated. So again, those are things you wanna look out for. That's it for this week. Go to the website, click on the links to read more about this. Go to roomnow.live.
You can register for on demand our 92 lectures which were fabulous. Real interesting lectures, great speakers. Register and you can run around in there and see all the great talks including mine. Talk to you next week.
Did I get that right? I did. Specifically, we're going talk about time to flare when withdrawing DMARR therapy or the timing of steroid use when doing a temporal artery biopsy. Or how about the timing of cortisone injections when doing surgery on a joint that you're injecting. This and more in this edition of the RheumNow podcast.
We're gonna start with, a tweet that I put out just yesterday, I believe, about NXP two antibodies. I find these fascinating. Number one, they're coming across our desk. If you order a myositis panel, a lot of the companies that are doing myositis antibody bottles, which used to be, you know, PL7, PL12, MI2, SRP, JO1, EJ, OJ, those things. But now they're adding in without really are asking for TIFF1 gamma antibodies and NXP two antibodies.
Very interesting. But I looked this up just again recently because I have a patient with dermatomyositis and extensive calcinosis cutis, and she's has, lo and behold, an NXP antibody. Now NXP-two and the TIF-one gamma antibodies are two new antibodies associated with, cancer, especially in adults. They can be seen in kids, but when seen in adults, there's a they seem to be associated with cancer. I believe eighty five percent of patients who have cancer and dermatomyositis will have NXP two or TIF one antibodies.
This along with the MDA five antibodies is a real new constellation to autoantibody profiling. But I want to talk about NXP-two. Again, it can be seen in kids, be seen in adults, can be associated with more severe myositis disease and very refractory myositis disease. But I learned just this week that one of the cutaneous manifestations seen with NXP-two is calcinosis and it can be widespread, it can be difficult to manage, it might well be the sole manifestation of disease. So that's something to look forward.
A recent article in Rheumatology, March 16, actually reviews this to some extent. Another interesting report was about ultrasound and identifying and these are findings by ultrasound. Not surprisingly, they looked at patients with psoriatic arthritis and psoriasis and use fibromyalgia patients. I thought that was going to be a control, but wait, no, they found an thesesial inflammation in sixty six percent of the PSA patients and oh, no. No.
No. Let me go back. Using ultrasound, everybody had antiscezial evidence of of involvement. Ninety plus percent in PSA and in psoriasis. Fibromyalgia was seventy five percent.
What? If you looked at just clinical manifestation of enthesitis, meaning you press on it and it hurts, much more prevalent in fibromyalgia, ninety two percent versus two thirds of patients with psoriasis or psoriatic arthritis. My point is, shouldn't emphesitis by ultrasound be more specific for the spondyloarthritis kind of diseases like psoriatic disease? Why is fibromyalgia showing up so positive? To me this looks like, AM stiffness.
We all love AM stiffness in rheumatology. We think it's the fabulous inflammatory marker that it is until you get to fibromyalgia patients when more than half of them have significant AM stiffness, and there goes your whole association with inflammatory disease. Anyway, I don't do a lot of ultrasound, but seeing this data about ultrasound, enthesitis and FM, one of you ultrasound mavens needs to explain to me and then I'll come back and tell the rest of the world why I shouldn't be so hard on ultrasound, as a tool in fibromyalgia. An interesting study was published by David Felsen and his colleagues looking at over eighty patients with medial knee OA and the efficacy of lateral wedge sole inserts. As you know, it's often used.
There's not a lot of data about its use. They looked at about 80 something patients and then did a pre screening test to show that that if you actually did use a lateral wedge insert that it might have enough corrective action to be beneficial in unloading OA of the knee, especially in the medial compartment. So in their study of sixty three preselected patients, they showed a significant reduction in, pain, for those that were taking or using the lateral wedge, insoles compared to those that were using a neutral sole. The problem is that the difference was really small 0.7 on a zero to 10 scale. So while significant numerically, not significant clinically, suggesting that there's probably only a limited number of patients who really will respond to lateral wedge insoles.
I can vouch for this. I actually had severe bilateral medial knee OA required knee replacement after about twenty years of almost bone on bone. I use lateral wedge sole inserts. I don't know why I use them, but I use them thinking it might be helping. I don't know that it really helped a lot.
It wasn't really clinically apparent to me. So I just went from research to my own anecdotal experience. This must be a good podcast. The Tara study looked at RA patients, almost 200 of them. They were in remission.
They were on a combination of a TNF inhibitor and a DMARD or actually a biologic and a DMARD. And then they withdrew the either the biologic or the conventional DMARD and looked at flare rates a year later. At one year, flare rates were similar between those who had a DMARD weaning of thirty three percent versus those who had a biologic weaning of forty three percent, suggesting maybe more benefit with the biologic, but these results were not significant. The authors concluded it doesn't matter, and maybe therefore you should try to withdraw the biologic being that it's like a billion times more expensive. Interesting study.
You know, I don't know why we're still doing weaning studies and withdrawal studies and cessation studies. This seems like to be a bit nonsensical because we've done this research already for the last almost ten years, really six years. The ACR guidelines are very, very clear that there's a risk when you taper. So you probably shouldn't taper. The guidelines say that, that if the patient has low disease activity, to taper would be a bad idea because everybody flares or too many are going to flare.
It also says that if you're in remission, you could probably taper some drugs but not stop any drugs, meaning you could probably taper the DMARD and continue the biologic. The study, the Tara study says maybe these are opposite, but you can't go off therapy because there are consequences to that. Patients are high flare rate and there's radiographic progression that is seen over time. Of course, the real issue on tapering is that patients want to do this anyway. So you need to be armed with the data about how successful this is gonna be.
Generally, data that you should be giving is quite negative. But if patients can get away with it, then congratulations, but it's only going to be a minority. The new drug, Romexizumab, say that three times fast, was approved by the FDA just recently. Its trade name is called Evenity. The drug, the anti sclerosin inhibitor was developed by Amgen and UCB.
After a bit of a rocky road and a complete response letter, the drug was approved. The price was announced this week. It's gonna be 1,800 a month or about $22,000 a year. Don't worry, it's not available yet, but it will be available later in the year. It is approved for only postmenopausal, osteoporosis patients who are at high risk for fracture.
The cost that has been quoted by Amgen is said to be 34 to 74% lower than as seen with TYMLOS and Forteo, the other bone building agents that are out there. Peripheral nervous system involvement and lupus, say, oh, I can't remember. Everybody's got numbness. I never know what that's all about. And is it worth pursuing?
Well, it turns out in a in a review of the literature, it's only seen in less than seven percent of patients with lupus. Most of those, actually not most of them, a third of them was, sensory polyneuropathy, a third were cranial neuropathies, and then as a smattering of other in very few cases of mononeuritis. The risk of peripheral neuropathy was seen with advancing age, advancing lupus activity and damage. So again, it's not that common, you're not probably going to see this in young lupus patients, hot new diagnosed lupus patients. It can be seen but it's pretty uncommon.
An interesting report comes from the VA study was reported in arthritis care and research, ACNR Care and Rheumatoid, Arthritis Care and Research, the sister journal to arthritis and rheumatism. Wait, now it's called Arthritis and Rheumatology. Why did they keep changing the names of these journals? Anyway, the VA study looked at temporal artery biopsy in GCA patients. The numbers here are staggering.
Over 3,000 temporal artery biopsies done, ten percent of them were positive. And they looked at the factors that were involved in yielding a positive result. They showed that the, you should everybody should know this, but I think the data that they came up with reinforces what should be known is that is the length of the biopsy that's most important. In fact, the length must be at least three centimeters to yield the greatest results. And by having a three centimeter or larger biopsy, you have a fifty eight percent increase odds of having a positive result.
Doing bilateral biopsies, generally, I don't do those, but if you're hell bent on making a diagnosis, diagnosis doing two rather than one, increases the odds of a positive result by eighty three percent. Age greater than 71 years is also a predictive factor. The interesting thing about this study and why it made the highlight reel here is that prednisone use up to forty two days prior to the biopsy did not influence biopsy results. So there's a little bit of conflict out there on this, but I don't think you should avoid a biopsy if someone has recently been started on steroids, which you must do. If you really think they have GCA, they could lose their eyesight, start them on 680mg of prednisone and get the biopsy ASAP.
Risk of gout. We know the risk factors for gout, you know, shellfish, alcohol, you know, hanging around in hookah bars. That's my own opinion. I've never been in a hookah bar, truth be told. So but we do know that there are some things that are protective too.
An interesting study from two large Chinese dietary studies shows that those who are eating a vegetarian plant based diet actually have a significantly lower risk up to a sixty percent lower risk of actually developing gout in the future. So avoid the alcohol, skip the sake, go for the vegetables, you'll do better in the long run. A nice article came out in the surgical or the surgical literature looking at the timing of shoulder corticosteroid injections in patients who ultimately underwent rotator cuff surgery. This is a very large cohort like thousands and thousands of patients and they compared those who had had a prior shoulder injection in the year prior to surgery versus those who never had. And they showed that having a shoulder steroid injection did not, adversely affect the outcomes and success of surgery or the complications thereof.
However, if that steroid shoulder injection was done within thirty days of the surgical procedure, guess what? Bad news, Charlie. The rates which were less than point eight percent now went up to one point three percent for those who had a recent injection. Therefore increasing the odds to one point seven or seventy percent increase if you had a recent injection. Risk factors for infection included male, obesity, smoking, diabetes, and again this perioperative steroid injection.
Our last report concerns risk factors with scleroderma and systemic sclerosis. They had two thirds of their patients had localized disease, one third progressive disease. In this particular study, they showed that there was an increased risk of mortality. Standard mortality rates were increased in scleroderma patients. That's not surprising.
Fairly low and the SMR was 5.73 in this particular study. A meta analysis of all the literature out there looked at this showed that the SMR was 3.45, suggesting it's higher. The one year, two year mortality rates are fairly low, but the five year mortality rate is about, fourteen percent. The ten year mortality rate is about twenty eight percent, in scleroderma and so that's kind of shocking. Reduced survival, elderly or over age 60, diffuse systemic sclerosis, scleroderma renal crisis, dyspnea, six minute walk time being prolonged, forced vital capacity less than 70%, DLCO less than 70%, pulmonary hypertension, telangiectasia, valvular heart disease, malignant malignancy anemia, and a CRP that's abnormal.
Another review of the literature showed pretty much the same profile, mortality being linked also to SCL 70 antibodies, but not linked to antisentromere antibodies, maybe a little higher on those with cardiac renal involvement, interstitial lung disease, pulmonary hypertension has been as has been stated. So again, those are things you wanna look out for. That's it for this week. Go to the website, click on the links to read more about this. Go to roomnow.live.
You can register for on demand our 92 lectures which were fabulous. Real interesting lectures, great speakers. Register and you can run around in there and see all the great talks including mine. Talk to you next week.
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