RheumNow Podcast- Knee Pain Knockout (1.10.20) Save

It's the 01/10/2020. I did say 2020, didn't I? This is the RheumNow podcast, and I'm Doctor. Jack Cush, executive editor of roomnow.com. This week, best therapies for dactylitis and enthesitis.

And guess what? We have a new knockout for knee pain in OA. And are you on the naughty or nicelist when it comes to the new ACR Arthritis Foundation guidelines for osteoarthritis? Tune in, you'll find out. Our first report is on early arthritis.

A large UK cohort followed prospectively and evaluated in three different time periods, starting with a diagnosis, I think in 1990, again in 2002, and then at 2010. If you were diagnosed at 2010, your ability, your likelihood of achieving a low disease activity score was going to be, guess what, fifty nine percent. However, if it was two thousand and two you were diagnosed, it was only forty eight percent. And in 1990, it is estimated that your likelihood of achieving an LDAS was only thirty two percent. You are getting better and there's the proof of it.

It's a little sobering though that these early arthritis, early inflammatory arthritis patients still in modern times, only sixty percent are achieving an LDAS. It is easier to get a better response in early disease. So we still have a long way to go. An interesting study was published this week about the comparative efficacy of intravenous versus oral antibiotic therapy in patients with septic bone, joint, or even prosthetic infections. And in this study of over a thousand patients, they showed that both groups actually had a very high success rate, about eighty five percent.

And that there was no difference in the outcomes, meaning that oral antibiotic therapy was not inferior to IV antibiotics and that the cost was about, I think it was 25% less. Is that going to become common practice? I think, again, it takes a while for such evidence to change practice. I think we'll need a few more studies like this, but there have been other studies that have suggested oral antibiotics can be as good as IV, especially with newer therapies. Now, is gabapentin a problem for you?

Is there a lot of abuse and misuse of gabapentin? Well, you know, I found a few reports last year that addressed this and yet we have another one. This is a claims data study that looked at the use of gabapentin by different clinics between the years 2003 and 2016, when 2016, I think there was like two sixty million clinic visits for gabapentin or gabapentinoid therapy prescriptions. Annual prescription rates actually quadrupled between 2003 and 2016. And who led the way?

No, it wasn't the rheumatologists. No, it wasn't the pain doctors even. It was actually primary care doctors responsible for almost half of the gabapentinoid prescriptions. Turns out that about a third of the patients were taking concurrent opioids and or benzodiazepines and fifteen percent of people taking gabapentin. So is gabapentin an abuse potential drug?

I think it runs in the family of drugs that are often abused. The benzodiazepines and the opioids tend to get a lot of gabapentin with the hope that they won't use so much benzodiazepines and opioids. Gabapentin itself has been reported to be responsible for hospitalizations and deaths and whatnot in drug interactions. I don't think it's entirely safe, but I don't think it deserves to be lumped in with opioids. That's my opinion, not the opinion of these authors.

So, dactylitis, enthesitis, these are the problematic manifestations in the spondyloarthropathies, especially psoriatic arthritis. This week, we noted a systematic literature review that looked at 18 trials in almost 7,000 patients and basically showed that TNF inhibitors, ustekinumab, secukinumab and ixekizumab, all of them gave a two to three fold higher response compared to placebos. And that they were basically equivalent in their ability to treat and manage dactylitis. Again, measuring those things are that kind of data is really only found in clinical trials, which is why they had to dig deep to find those trials that could look at that. But there's good evidence for the drugs I just mentioned.

Now, if I told you I have a treatment for fibromyalgia that would work in seventy percent of patients compared to thirty one percent who are getting placebo, you'd think, steroids? Well, no, not really. You know, steroids do work in some, but not many fibromyalgia patients. I have a study here of three zero one fibromyalgia patients who were randomized to receive TENS therapy, that's transcutaneous why am I having a hard time saying that? Transcutaneous electrical stimulation devices or placebo TENS or no TENS at all.

Patients were given treatment twice a day at home for four weeks. This is a short term study. It's a good size study, 300 patients. And guess what? Active TENS did much better as far as pain reduction and fatigue improvement.

Why that would improve? Who knows? Compared to placebo. And it was much better as compared to placebo and even the fake TENS as far as global improvements, seventy percent improving on TENS compared to thirty one percent. Now don't ask me what the global improvement scale is all about, but I think this is kind of interesting and I have some patients who tried this, maybe we should look at this more.

An interesting report comes from the Journal of Rheumatology, which looks at the issue of what you do in an RA patient who develops cancer. What do you do as far as future therapy? Well, for this particular study, they looked at their corona registry. The corona registry, as you know, is a very large prospective registry. At the time of this study, they had forty three thousand rheumatoid arthritis patients in their registry.

They called and they find eight, also actually nine hundred plus patients who had a new solid cancer. After they imposed criteria was they studied eight eighty such patients and looked at what happened to them after they developed their cancer. At the time of diagnosis or the incipient event, which was cancer, forty two percent were either taking a biologic or a drug like the JAK inhibitors, the TSD marks. Those people who were on them, you know, for each individual, for biologics, it was about a third, guess what? They stayed on them throughout the time of follow-up.

Now, the follow-up was lost over time. So again, it was about, of the eight eighty, it was about two seventy who were taking a biologic and over time, over five year period, that did wean down. But those who stayed in the study and were being followed, they actually stayed on the same drug throughout. Of the ones who were not, so there's about six hundred plus patients who were not on a TS DMARD or a biologic DMARD. And five percent of them went on to actually start a biologic.

And ten percent, sorry, ten percent started new biologic, five percent of the other ones switched to biologics. The point being, a high percentage of patients in the corona registry either stayed on their therapy, switched biologics after the diagnosis of a cancer, or those who had just on, were on DMART therapy, conventional DMARTs, some of them actually started new biologics. That's ten percent. And they had a little bit more disease activity when you looked at them. Most people that were on biologics at the time of diagnosis were taking TNF inhibitors and they stayed on them, more than half.

And those that switched to a new biologic went up mostly on TNF inhibitors. So again, ACR guidelines are very clear on this. They say, if your patient has a solid malignancy, you should treat them as if they didn't have a solid malignancy, meaning there's no risk. You give them whatever biologic, whatever DMARC you want because the data is very clear. So I would say that the practitioners within the corona registry are starting to live up to that, but not everyone is.

They still get questions and emails about this, what do I do? Patient has pancreatic cancer, what should I start? And again, tumor, do whatever you want, Joe. I mean, it doesn't really matter. The data is very, very clear.

We could argue what happens with hematologic cancers like lymphoma, leukemia, but that's another report another time. An interesting study comes out. We see two of these now, dose trivalent influenza vaccine and inactive vaccine was studied in almost seven hundred RA patients compared to standard dose quadrivalent flu vaccine. And guess which did better? Well, again, no contest here.

Seroconversion rates were at least threefold higher when you use a high dose influenza vaccine. Heretofore previously recommended only for the elderly, but you know, really probably should be used in your rheumatoid more so than the standard dose. The issue is, is it available and what the cost is? Again, I don't have it in my clinic and have the standard dose, but I am recommending more and more now that my patients go to the pharmacy to get the high dose. They seem to like it.

They think they're sort of special getting the high dose, they're supersizing their influenza vaccine. There were no differences in side effects and other untoward effects and there were no flares of rheumatoid activity in that study. A very large 12,000 patient claims data study shows that rheumatologists not so good at screening for hyperlipidemia in rheumatoid arthritis patients. It was suboptimal and that's even being compared to diabetes patients not being followed by rheumatologists. Turns out that the ones who are more likely to be screened are ones who had a primary care doctor and a rheumatologist.

But then again, isn't that the primary care doctor's job and not my job? You know, it really is, but you need to take responsibility because you understand the comorbidity of rheumatoid arthritis. You should know enough to look for hypertension, hyperlipidemia, diabetes, osteoporosis, the things that will kill your rheumatoid and add to their misery. And then you should obviously instruct the patient and get the partnership with a good primary care doctor. Again, we need to step up on that.

I thought the most interesting study of the week, I actually found by reading Helio, was genicular artery embolization in patients who have osteoarthritis of the knee. It's either genicular artery or geniculate artery. In this particular study, it was a pilot study of twenty patients who had osteoarthritis of the knee refractory to standard therapy, meaning nonsteroidals and other analgesic therapies. This is not the first study. Was actually first done in back I think 2014 and has been repeated a few times, all open label trials, all really quite successful, some showing up to three years of improvement.

In this particular study, the objective was to show improvement either by MRI, by visual analog scale or by Woolmax scores, the standard outcome measure for osteoarthritis of the knee. So all patients that have successful embolization, they use a small 50 to 75 nanometer sized particles to embolize the genicular arteries and there's a bunch of them. Look it up someday. You'll see these are arteries that are branches off of the femoral as you come down above the knee, it branches off into a medial, lateral, an anterior superior. There's a whole bunch of them.

It's sort of a lattice work of arteries. And the idea is that they go in and by digital angiography, they go and they find out where there's a high density of these arteries, a blush if you will, to show that this is where we're going to go. That's where the activity is. And they then embolize that. And they were successful in embolizing at least one artery in all of the twenty patients.

Improvement was very reasonable. As far as VAS, I assume this is VAS pain from 76 down to 29. And Womack scores dropped by more than 50% from 61 down to 29 as well. Again, is this working by embolizing the blood supply to synovitis and synovium? Is this somehow addressing the issue of osteoangina at the level of bone that can cause pain and osteoarthritis?

It works. Would it work in controlled trial? I think we need to see more studies on this, but I think this is a really nice result. The COAST X study, the COAST 10 study, I don't know if it's X or 10 or if we're following that kind of scheme, was a study of ixekizumab in patients with non radiographic axial spondyloarthritis. You know, this has sort of been a hot area recently, this past year.

Cerdulizumab, Cimzia was approved for non radiographic axial SpA. And now in this trial, they showed significantly better responses compared to placebo. In three hundred patients treated with ixekizumab in two different ways compared to placebo. At sixteen weeks, it was like forty percent for ixekizumab either regimen versus twenty percent, nineteen percent with the placebo. And that kind of persisted out to week fifty two, no new side effects.

We will have therapies that will be FDA approved for non radiographic axial SpA. Those are axial spondyloarthritis patients who don't have the x-ray evidence that you need, but will have either the symptoms of inflammatory back pain, a high CRP or an abnormal MRI to qualify that diagnosis. I think this is a major advance. Of course, the problem is, do we have a lot of these patients? Do we really need this indication?

And what in the world is the ICD-ten code for non radiographic axial spondyloarthritis? Lastly, a report from the Arthritis Foundation and the ACR who got together and devised some new treatment guidelines for osteoarthritis of the hand, knee, and hip. These were presented at ACR twenty nineteen in Atlanta just a few months ago. I went to the presentation, it was a little bit testy. There were a lot of things that were in favor last time in 2012 and now we're there against them.

There was a lot of flips in here. And I think you need to read the guideline and read the recommendations to see if you're in compliance. So for instance, they recommend a self management programs like use of Tai Chi to help and yoga to help hip and knee OA, topical NSAIDs and NSAIDs for knee and hand OA. Again, a conditional recommendation for topical capsation. Last time they were against capsation for knee OA.

And a new strong recommendation against TENS and hyaluronic acid injections in OA in multiple forms. A lot of things they came out as being against. That includes things like iontophoresis, manual therapy, massage therapy, modified shoes, wedge insoles, surprise, surprise, a pulse vibration therapy, that sounds like voodoo. Therapies that are prescribed and also failed as far as the committee goes are bisphosphonates, glucosamine, hydroxychloroquine, methotrexate, TNF inhibitors, biologics in general, stem cell injections, that's a special kind of nuts. Chondroitin by itself.

Again, a lot of things didn't do very, very well. What did do well? Exercise, balance training, weight loss, obviously, tai chi, yoga, cognitive behavioral therapy, use of canes and tibiofemoral knee braces. These are things that I think that we should be using more and more of. But look at the guidelines.

I think you'll be surprised whether you're in compliance or not. Don't forget, RheumNow live, 03/13/1415, just a few months away in Downtown Fort Worth. Great meeting, sign up now. We have a few remaining spots. It's gonna be a fabulous meeting.

And I think that you'll enjoy our speakers. You can go to the website and see our program and what's out there. Again, great rheumatologists like us go to great meetings like this. See you next week on the podcast.