RheumNow Podcast- Half - Empty Flu (2.21.20) Save
Dr. Jack Cush reviews the news and journal articles from the past week on RheumNow.com
YouTube Link: https://youtu.be/9soH1KbtosM
Transcription
It's the 02/21/2020. This is the RheumNow podcast. I'm doctor Jack Cush, executive editor of rheumnow.com. You know, I just had my teeth cleaned today. I'm wondering if my CCP antibody levels are up.
Do you have vitamin D fatigue? Lord knows I do. And a startling new revelation on the acronyms BARF and VOMET and their applicability to rheumatologists. We'll start with a great review article, actually a meta analysis from Nicola Dalbeth and Philip Robinson from way down under where they talk about colchicine toxicity. 35 studies, I think 8,000, 9,000 patients, they reviewed the toxicities of colchicine, a drug I no longer use.
Check out QD 78 on YouTube or the, video I just did, the QD clinic called, my acute gout. But nonetheless, colchicine gives you a higher risk of things you know, diarrhea, a two and a half fold risk. Twenty percent of patients will get diarrhea on colchicine. GI events, almost twenty percent there too, 1.7 fold higher risk. Liver toxicity, I didn't know about.
It's almost significant at almost two percent, one point nine percent, but not quite significant, neither was muscle events. There were no reports of neuropathy, deaths, or infections with colchicine. Is it a safe drug? Is it a 200 year old drug? Yes.
It is. Do I use it? No. I don't. Congratulations to those of you who do.
There are better ways and easier ways to manage gout. According to the CDC, they came up with some new numbers on the effectiveness of this year's seasonal flu vaccine. And drum roll, please, the data from October to January says that the flu vaccine was forty five percent effective in preventing medically attended laboratory confirmed cases of influenza. That's half empty or half full. Clearly, we're not doing a good enough job getting a large number of our patients vaccinated, so there's a half empty kind of story.
But knowing that half of them benefited from that is still a good tune, and it only gets better in subsequent years. Again, I think it's an important intervention for those important patients who really need it. If you are at the great conference this past week in Maui RWCS, the Rheumatology Clinical Winter Symposia. We had a number of great lectures. You can go to that website and see them, and hear them.
Doctor William Bugby, an orthopedist and great friend to many rheumatologists. He's from La Jolla, had a fabulous set of lectures on issues that we're really concerned about. He laid out these two acronyms, BARF and VOMID. BARF stands for, guess, blindness application of radiologic findings. Barf.
Can you spell it? VOMET stands for victim of medical imaging technology. I think there's a lot to be said here about the appropriate use of imaging. A recent tweet we put out says that in a study of three hundred and nineteen women with rheumatoid arthritis, thirty percent had a high rate of depression or higher than expected rate of depression compared to only twelve percent in the control population suggesting suggesting that that this was significantly higher. And more importantly, that depression was associated with disease activity and disability scores as measured by HAC.
Now this was a study of women. Would the same be seen in men or a mixed population? That's not been like, it's been hinted at in other studies. It seems like this could be something more prevalent in women more so than men, but it is something that we generally don't pay enough attention to and probably should. I hate to break this to you rheumatologists.
You guys love methotrexate. You love, you know, morning stiffness. You love vitamin D. You test for it. You treat it.
You you vitamin D crazy rheumatologist. But, unfortunately, in a study of a hundred and sixty nine patients looking at disease activity and whatnot, and number of measures including fatigue, vitamin d levels were not associated with fatigue. Although it's often stated that you feel might feel bad and you because of vitamin d and then we supplement, you might could get better. Well, that's actually not true based on this cross sectional analysis. Yet, fatigue was associated with disease activity and psychologic distress and pain, but vitamin d levels sadly so were not.
A study from the Slovenian National TB Registry looked at the rate of getting TB amongst the population of people who are taking TNF inhibitors, largely RA, but AS and PSA included, six percent of their twenty five hundred patients were required to take TB TB chemoprophylaxis for LTBI, and that occurred in both RA and PSA. A few, something like six or eight patients developed TB in that population, a very low rate, and two patients died from TB. So that's nothing to, to shirk off the rates that they noted of TB incidence for their TNF inhibitor treated population was forty five to fifty one PSA and RA respectively, I believe, per 100,000 patients. In The United States, the risk of TB is roughly three to five per one hundred thousand patients. In Slovenia, they have a similar rate actually.
It's not an endemic country. The rate is about five per one hundred thousand. That means an RA patient who goes on TB therapy in Slovenia has a tenfold greater risk of getting TB. That's about the numbers that have been thrown around in the past, a six to ninefold increased risk when you're exposed to TB and have an inflammatory disease like RAP SA or AS. Some lessons from Slovenia that are useful here in The United States, UK, Australia, etcetera.
The FDA has approved diclofenac gel, also known as Voltaren gel, for patients with arthritis pain and, osteoarthritis. It is suggested that it can be, take up to seven days to work and can it can be used for up to three weeks. If you're gonna use it more than three weeks, consult your local rheumatologist, of course. A reasonable study was done on RA patients and the risk of periodontal disease. A hundred and thirty nine patients had dental exams and evaluations, and these patients who did have periodontal disease and they had three or four different measures of periodontitis showed that it was highly correlated with anti CCP antibodies in those individuals.
This is one brought out before. I think this is another study that reaffirms those findings. I posted, a Still's disease report. Fourteen patients from Mainland China treated with tofacitinib for refractory adult onset Still's disease. Refractory, we would assume to IL six therapy methotrexate steroids because in that country, they don't have access to IL one inhibitors.
They were given five milligram BID of tofacitinib, and the results were really quite striking. I think it was fifty percent of them went to complete remission responses usually within a month. There was, six patients had partial remission. There were two patients who didn't respond at all. It could be an alternative therapy.
It is not FDA approved. It has not been studied, but there are a number of anecdotal reports now showing that tofacitinib and other JAK inhibitors do work in a number of conditions including alopecia universalis and atopic skin disease and dermatomyositis, and we can now add Still's disease probably to that list. I'd like to see some studies in this area. Georg Chet published a nice piece in science and translational medicine about the effects of JAK inhibitors on osteoclast suggesting that inhibiting JAK may result in an increase in osteoblastic function without affecting osteoclastic activity, and that may be one of the many reasons why JAK inhibitors have been shown to retard the development of erosions in rheumatoid arthritis. We're talking about baricitinib and tofacitinib here where they in animal models, they actually use them and showed that you could get upregulation of osteoclast osteocalcin and Wnt signaling as indicative as as indicative of osteoblastic activity.
It's a nice new mechanism for maybe how JAK inhibitors might work in inflammatory arthritis. Lastly, I'll end with the reminder report that finally came out from Dan Solomon in Annals of Internal Medicine this week on the safety of methotrexate. As you know, Dan reported the results of almost five thousand patients exposed to methotrexate in the CERT study, c I r t, that's the cardiovascular risk intervention trial in high risk cardiovascular patients, not arthritis patients who got methotrexate or placebo and he showed you the toxicities. So we know there's a seventeen percent increase in mild to moderate toxicities. Most of the things that you're aware of, a few of the high points that you should take home from this taken from a nonrheumatoid population.
Methotrexate pneumonitis seen in six people on methotrexate and no cases or one case on placebo with a hazard ratio of almost seven, and that was a significant difference. All these people were on low dose methotrexate fifteen to twenty milligrams per week. All of them were on folic acid. Pneumonia was not increased in patients taking methotrexate, whereas all other infections, non serious infections, were slightly increased. Leukopenia and anemia had about a thirty six to forty six percent increase that was significant, but there was not an increased risk of thrombocytopenia when taking methotrexate and pancytopenia was rare, rare, rare.
Skin cancers were were it seems to be the headline. A lot of other reports on this report, I don't think that's that important, but skin cancers, twofold increase in patients taking methotrexate, and that's been reported in RA patients on other DMARDs too, so it's hard to say what that means. Cirrhosis was seen in five people on methotrexate and none of the people taking the placebo compare comparison, all the patients who developed cirrhosis had were diabetic. None of them were drinking alcohol or heavily into alcohol, and three out of the five had repeated LFT elevations, meaning more than five out of nine LFT's were within the abnormal range, and none of them were sky high elevations of LFT's. They were just, you know, forty two to 86 transaminitis kind of elevations.
That's it for this week on the RheumNow podcast. Check out rheumnow.live. We still have registration open. It's gonna close soon. There's sixteen hours of CME, a weekend away from work.
Friday to Sunday, you'll be home watching, sixty minutes, at 6PM on Sunday. The meeting's in beautiful downtown Fort Worth where it's gonna be 75 and sunny. We'll see you in Fort Worth in four weeks.
Do you have vitamin D fatigue? Lord knows I do. And a startling new revelation on the acronyms BARF and VOMET and their applicability to rheumatologists. We'll start with a great review article, actually a meta analysis from Nicola Dalbeth and Philip Robinson from way down under where they talk about colchicine toxicity. 35 studies, I think 8,000, 9,000 patients, they reviewed the toxicities of colchicine, a drug I no longer use.
Check out QD 78 on YouTube or the, video I just did, the QD clinic called, my acute gout. But nonetheless, colchicine gives you a higher risk of things you know, diarrhea, a two and a half fold risk. Twenty percent of patients will get diarrhea on colchicine. GI events, almost twenty percent there too, 1.7 fold higher risk. Liver toxicity, I didn't know about.
It's almost significant at almost two percent, one point nine percent, but not quite significant, neither was muscle events. There were no reports of neuropathy, deaths, or infections with colchicine. Is it a safe drug? Is it a 200 year old drug? Yes.
It is. Do I use it? No. I don't. Congratulations to those of you who do.
There are better ways and easier ways to manage gout. According to the CDC, they came up with some new numbers on the effectiveness of this year's seasonal flu vaccine. And drum roll, please, the data from October to January says that the flu vaccine was forty five percent effective in preventing medically attended laboratory confirmed cases of influenza. That's half empty or half full. Clearly, we're not doing a good enough job getting a large number of our patients vaccinated, so there's a half empty kind of story.
But knowing that half of them benefited from that is still a good tune, and it only gets better in subsequent years. Again, I think it's an important intervention for those important patients who really need it. If you are at the great conference this past week in Maui RWCS, the Rheumatology Clinical Winter Symposia. We had a number of great lectures. You can go to that website and see them, and hear them.
Doctor William Bugby, an orthopedist and great friend to many rheumatologists. He's from La Jolla, had a fabulous set of lectures on issues that we're really concerned about. He laid out these two acronyms, BARF and VOMID. BARF stands for, guess, blindness application of radiologic findings. Barf.
Can you spell it? VOMET stands for victim of medical imaging technology. I think there's a lot to be said here about the appropriate use of imaging. A recent tweet we put out says that in a study of three hundred and nineteen women with rheumatoid arthritis, thirty percent had a high rate of depression or higher than expected rate of depression compared to only twelve percent in the control population suggesting suggesting that that this was significantly higher. And more importantly, that depression was associated with disease activity and disability scores as measured by HAC.
Now this was a study of women. Would the same be seen in men or a mixed population? That's not been like, it's been hinted at in other studies. It seems like this could be something more prevalent in women more so than men, but it is something that we generally don't pay enough attention to and probably should. I hate to break this to you rheumatologists.
You guys love methotrexate. You love, you know, morning stiffness. You love vitamin D. You test for it. You treat it.
You you vitamin D crazy rheumatologist. But, unfortunately, in a study of a hundred and sixty nine patients looking at disease activity and whatnot, and number of measures including fatigue, vitamin d levels were not associated with fatigue. Although it's often stated that you feel might feel bad and you because of vitamin d and then we supplement, you might could get better. Well, that's actually not true based on this cross sectional analysis. Yet, fatigue was associated with disease activity and psychologic distress and pain, but vitamin d levels sadly so were not.
A study from the Slovenian National TB Registry looked at the rate of getting TB amongst the population of people who are taking TNF inhibitors, largely RA, but AS and PSA included, six percent of their twenty five hundred patients were required to take TB TB chemoprophylaxis for LTBI, and that occurred in both RA and PSA. A few, something like six or eight patients developed TB in that population, a very low rate, and two patients died from TB. So that's nothing to, to shirk off the rates that they noted of TB incidence for their TNF inhibitor treated population was forty five to fifty one PSA and RA respectively, I believe, per 100,000 patients. In The United States, the risk of TB is roughly three to five per one hundred thousand patients. In Slovenia, they have a similar rate actually.
It's not an endemic country. The rate is about five per one hundred thousand. That means an RA patient who goes on TB therapy in Slovenia has a tenfold greater risk of getting TB. That's about the numbers that have been thrown around in the past, a six to ninefold increased risk when you're exposed to TB and have an inflammatory disease like RAP SA or AS. Some lessons from Slovenia that are useful here in The United States, UK, Australia, etcetera.
The FDA has approved diclofenac gel, also known as Voltaren gel, for patients with arthritis pain and, osteoarthritis. It is suggested that it can be, take up to seven days to work and can it can be used for up to three weeks. If you're gonna use it more than three weeks, consult your local rheumatologist, of course. A reasonable study was done on RA patients and the risk of periodontal disease. A hundred and thirty nine patients had dental exams and evaluations, and these patients who did have periodontal disease and they had three or four different measures of periodontitis showed that it was highly correlated with anti CCP antibodies in those individuals.
This is one brought out before. I think this is another study that reaffirms those findings. I posted, a Still's disease report. Fourteen patients from Mainland China treated with tofacitinib for refractory adult onset Still's disease. Refractory, we would assume to IL six therapy methotrexate steroids because in that country, they don't have access to IL one inhibitors.
They were given five milligram BID of tofacitinib, and the results were really quite striking. I think it was fifty percent of them went to complete remission responses usually within a month. There was, six patients had partial remission. There were two patients who didn't respond at all. It could be an alternative therapy.
It is not FDA approved. It has not been studied, but there are a number of anecdotal reports now showing that tofacitinib and other JAK inhibitors do work in a number of conditions including alopecia universalis and atopic skin disease and dermatomyositis, and we can now add Still's disease probably to that list. I'd like to see some studies in this area. Georg Chet published a nice piece in science and translational medicine about the effects of JAK inhibitors on osteoclast suggesting that inhibiting JAK may result in an increase in osteoblastic function without affecting osteoclastic activity, and that may be one of the many reasons why JAK inhibitors have been shown to retard the development of erosions in rheumatoid arthritis. We're talking about baricitinib and tofacitinib here where they in animal models, they actually use them and showed that you could get upregulation of osteoclast osteocalcin and Wnt signaling as indicative as as indicative of osteoblastic activity.
It's a nice new mechanism for maybe how JAK inhibitors might work in inflammatory arthritis. Lastly, I'll end with the reminder report that finally came out from Dan Solomon in Annals of Internal Medicine this week on the safety of methotrexate. As you know, Dan reported the results of almost five thousand patients exposed to methotrexate in the CERT study, c I r t, that's the cardiovascular risk intervention trial in high risk cardiovascular patients, not arthritis patients who got methotrexate or placebo and he showed you the toxicities. So we know there's a seventeen percent increase in mild to moderate toxicities. Most of the things that you're aware of, a few of the high points that you should take home from this taken from a nonrheumatoid population.
Methotrexate pneumonitis seen in six people on methotrexate and no cases or one case on placebo with a hazard ratio of almost seven, and that was a significant difference. All these people were on low dose methotrexate fifteen to twenty milligrams per week. All of them were on folic acid. Pneumonia was not increased in patients taking methotrexate, whereas all other infections, non serious infections, were slightly increased. Leukopenia and anemia had about a thirty six to forty six percent increase that was significant, but there was not an increased risk of thrombocytopenia when taking methotrexate and pancytopenia was rare, rare, rare.
Skin cancers were were it seems to be the headline. A lot of other reports on this report, I don't think that's that important, but skin cancers, twofold increase in patients taking methotrexate, and that's been reported in RA patients on other DMARDs too, so it's hard to say what that means. Cirrhosis was seen in five people on methotrexate and none of the people taking the placebo compare comparison, all the patients who developed cirrhosis had were diabetic. None of them were drinking alcohol or heavily into alcohol, and three out of the five had repeated LFT elevations, meaning more than five out of nine LFT's were within the abnormal range, and none of them were sky high elevations of LFT's. They were just, you know, forty two to 86 transaminitis kind of elevations.
That's it for this week on the RheumNow podcast. Check out rheumnow.live. We still have registration open. It's gonna close soon. There's sixteen hours of CME, a weekend away from work.
Friday to Sunday, you'll be home watching, sixty minutes, at 6PM on Sunday. The meeting's in beautiful downtown Fort Worth where it's gonna be 75 and sunny. We'll see you in Fort Worth in four weeks.
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