RheumNow Podcast – LTF – Listen To Fauci (7.17.20) Save

It's the 07/17/2020. This is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This week, narcotic no nos, SARS CoV two synovitis.

Say that fast SARS CoV-two Synovitis, only a rheumatologist could, and most importantly, LTF. Those will follow, but first, a report about risks with inflammatory myositis. Idiopathic inflammatory myositis, we used to just call this polymyositis, dermatomyositis. Now, it's got a proper name IIM. Well, an interesting study looked at six hundred IIM patients and compared them to four thousand Rheumatoid and four thousand controls and looked at the overall risk of cardiovascular events showing like Rheumatoid Arthritis, Inflammatory Myositis has a significantly higher risk, has a ratio of one point four five, corrected has a ratio of one point three eight, hence about a forty percent increased risk of cardiovascular events with myositis.

This was roughly equal to that seen in rheumatoid arthritis patients. So interestingly, this was mostly MI and not, stroke risk. And the other interesting thing here is that while the risk of cardiovascular events persisted over time in RA, the risk in inflammatory myositis only persisted the first five years. Now why is that? I'm not really sure maybe it's better control of the disease over time, but it's an interesting observation nonetheless.

I put up a tweet about dysphagia. I've often been, enamored for some strange reason with dysphagia in inflammatory myositis. I think it could be signs of a serious medical emergency. Such patients, who have upper pharyngeal dysphagia, that's where all the skeletal muscle is as you know, are at higher risk for aspiration, higher risk for not just swallowing problems, but really it seems to associate with a higher risk overall of more serious disease and should be taken seriously. The only other thing that gives you upper pharyngeal dysphagia would be dry mouth and xerostomia, not enough saliva so to speak.

So, in this particular analysis of the literature looked at the risk, of having dysphasia with myositis was thirty six percent and it's often presenting feature. The other interesting factor in this particular report was it was more common in patients who have inclusion body myositis. It's also not uncommon in cancer associated myositis and NXP-two associated, inflammatory myopathy. Watch for dysphasia, it's a bad sign. Ghent University did a very interesting analysis, one that sort of surprised me.

I tend to think of, systemic sclerosis patients as sort of being discrete subgroups, that there's who have those are there are those who have diffuse disease, those who have linear disease or localized forms, etcetera. Well, in this particular study, they actually did a review and also looked at their own experience at Ghent University and showed that amongst all scleroderma patients, there is a subset of people who have both diffuse and localized scleroderma, occurring in roughly two point five to seven point five percent of patients. These people will also have Raynaud's, they'll often have abnormal nail fold capillaroscopy findings that are compatible with scleroderma, and they will often have diffuse scleroderma specific autoantibodies. So, again, you can have both, I've often thought that you get one, you don't get the other, well, you could, in up to seven point four percent of patients. There were two simultaneous reports in the last week about the occurrence of coronavirus or CoV-two, COVID nineteen synovitis in patients, some patients who had no prior history of arthritis and some who actually did.

So, in this one report from, anal traumatic disease, had two cases from Italy, one had no prior arthritis, one had RA, they both developed worsening or onset of a polyarthritis upon hospitalization for the SARS CoV-two infection. They both patients had COVID pneumonia, and whatnot. Synovial biopsy was done in both cases. One had crystals, but nonetheless both had, infiltration with CD three positive T cells and CD 138 positive, differentiated plasma cells that and that was sort of you could get that with RA, but only one of these people had rheumatoid arthritis. There was another report in Lancet Rheumatology that also described the onset of a symmetric peripheral polyarthritis in a patient previously diagnosed with spondyloarthropathy, and this occurred following a SARS CoV-two infection.

So the question is, can the SARS CoV-two infection, bring on inflammatory arthritis by itself? Is it more likely in people who have pre existing arthritis? Remains to be seen, but these are the first few reports of patients who have synovitis following the COVID nineteen infection. JAMA Internal Medicine had an interesting report about the increase in antimalarial prescriptions, following the pandemic. From February 2020, hydroxychloroquine prescriptions more than doubled or from 300,000 to almost 700,000, actually was an 86% increase, and that chloroquine prescriptions had a 160% increase rising from 2,000 to over 6,000 prescriptions in the same time period.

Obviously, there's a lot of craziness about the use of hydroxychloroquine. Although the literature has been sort of, consistent in showing either no effect or negative effects with antimalarial use, there's been a few recent reports suggesting, hey, it might actually work, especially if given early. I don't know that it's the that the the the coffin is closed on hydroxychloroquine and, the coronavirus yet. I think we still need more good reports. And, you know, all the good reports are still to come because thus far what we've seen are preprints and early reports and press releases.

There's an interesting report from the, UK, Clinical Practice Research Datalink, a large database looking at the association between rheumatoid arthritis and what happens when you use steroids. In this particular study of, almost 18,000 new onset RA patients who were not on steroids, forty two percent of them went on to receive steroids, guess what? A subset of them went on to develop hypertension. Now, maybe that's not, surprising to you, but I don't think I've ever seen a good reference that tells me that steroid use can cause hypertension in our patients in whom we use them. Hence, another good reason why we should not use them, use them temporarily, or keep them at an absolute low, level.

The risk of developing hypertension was sixty four cases per one thousand patient years, and that glucocorticoid use increased this rate, by seventeen percent or a hazard ratio of one point one seven. The risk of hypertension was, as you would imagine, higher in people taking higher doses, those at seven point five milligrams and above. The CATCH cohort from Canada had an interesting report this this, week, looking at those who are, treated with methotrexate monotherapy, either subcutaneously or oral. These were almost fifteen hundred incident early RA patients enrolled, in that cohort over a ten year period. Subcutaneous methotrexate, the parenteral form, had fewer drug changes, subsequent drug changes, forty five percent versus eighty percent on the PO with PO methotrexate, and it had a longer duration of treatment.

The only thing that seemed to match this was the use of biologics or triple DMAR therapy also had a longer time period without treatment changes. Again, we don't use a lot of parenteral methotrexate in The United States. As an adult rheumatologist, I was always surprised to see the pediatric population was often more often treated with parenteral methotrexate than the oral form. And there's a lot of good reasons for it. And I think that there are good reasons here, not only cost reasons, we certainly know there's not an issue of absorption when you're using parenteral.

And there's some evidence certainly to say that it's more efficacious. Maybe the big announcement of the week was the FDA announcement that guselkumab, also called Tremfya, was approved for active psoriatic arthritis patients, making it the first IL-twenty three inhibitor to be approved for psoriatic arthritis. We do have IL-twenty three agents being studied in psoriasis and, risankizumab or SKYRIZI is approved for psoriasis, not for the psoriatic arthritis. This was approved for psoriatic arthritis. The approval is based on two very large phase three trials called DISCOVER one, DISCOVER two.

We heard from Atul Diadar telling us about those, those that dataset in past meetings. It is going to be approved at the same dose used for psoriasis, a hundred milligrams given roughly every eight weeks after you have two doses, loading doses at week zero and week four. That's now online and soon will be available. So two reports about the use of narcotics, which irked me a little bit. An EMR analysis of almost 500 patients treated in the emergency or gout patients treated in the emergency room or in the hospital shows that twenty eight percent of them received opioids at discharge from the hospital.

Most of these were newly diagnosed gout patients. So maybe there's an issue of undiagnosed or uncertainly diagnosed, gout patients. The average dose was thirty eight milligrams of morphine equivalent given for a median of eight days. This seemed to be more common in also in people who had polyarticular gout, diabetes, and those who had previously received opioids. Again, I don't know that we need narcotics to manage gout.

It certainly speaks to the severity of pain, that gout can bring on, but there are certainly safer, more effective therapies. Maybe equally bothersome is a report from, the CDC and MMWR just yesterday showing that in a two thousand nineteen survey of pregnant women, six point six percent of women received opioids during pregnancy. And this is these are women who admitted to receiving opioids during pregnancy. Twenty one percent said that they were miss misusing it, that they shouldn't have been on it, but they were misusing it. Twenty seven percent said that they were hoping that they could stop it or reduce it.

And maybe more surprisingly, that one third of the of the patients said that they had not received any counseling from the provider about how opioids could adversely affect, fetus and infant. Again, another situation where opioids probably should not be used. Again, that UK clinical practice registry had an interesting study of mortality risk in lupus. They studied four thousand three hundred lupus patients, and compared them one to six controls, so that compared to twenty four thousand control patients, that lupus patients overall had an eighty percent increase in mortality, a hazard ratio of one point eight. This was especially so, or the mortality risk was largely for infection, cardiovascular reasons, respiratory reasons, and accidents and suicide were also made like the top five reasons.

There was a higher risk of mortality with the younger onset of lupus and that there was a chronic use of corticosteroids. Interestingly, the use of hydroxychloroquine lowered the overall mortality risk in lupus. The New England Journal yesterday had an interesting report on cells that can be found in the periphery that may antedate and predict flares in rheumatoid arthritis patients. This particular study talked about prime cells. These are CD45 negative, CD31 negative pre inflammatory stem cells, they call them prime cells that are found in the blood.

So they did some genomic analysis, cell flow cytometry analysis on one index patient, and they actually did like 300 or 400 different, blood lettings and data collections, and they and they did this over a four year period during which there were, eight flares in that patient. They they showed the same results in another three patients where they had a few 100, again samples. Basically, showed that these prime cells would arise after, signs of B cell activation, that they would go up and then with the flare, they would go down. An interesting finding suggesting that maybe this is a new way to identify patients who are in a flare. Somewhat impractical, I would say, except if you're going to do a clinical trial, you don't want to enroll people who have an impending flare.

And I think most of what we do with regard to flares of rheumatoid arthritis are certainly archaic. We don't understand flares, we get and there are multiple, multiple reasons for flares, yet what do we do for flares? They all get steroids, intra articular, oral, you know, any way you can imagine, you know, I think that not all flares should be treated the same, maybe this takes us one step closer to identifying those who may respond to one type of therapy or another. Lastly, the New England Journal had an interesting letter to the editor, which was a comment by the original authors about their policies on mask wearing to prevent the COVID-nineteen infection. And they made the strong point that number one, everyone should wear masks.

And the idea here is of course that, you may not want to wear a mask, you may not think you need to wear a mask. The problem is those who are infected often do not know. The vast majority of us who will get infected do not know we are infected and we are asymptomatic. I heard one quote a few weeks ago said there are two types of people in this world, those who've got, who've had the coronavirus and those who are gonna get it. With that in mind and trying to limit the, damage of this pandemic, mask wearing is essential.

They also mentioned an important point that the risk of transmission is directly correlated with the duration and the intensity of close contact. So this is really important in close quarters, less important when you're outside. So, you if you're walking and running and riding a bike you don't need to wear a mask because you're doing a drive by and you're outdoors. However, if you're going to stop and talk to those three people and get close to them, you probably do need to be wearing a mask. Bottom line is LTF.

Listen to Fauci. I'm not sure why Fauci has fallen under a critique. He's the only smart person at the table on this issue. This is too serious to be listening to listening to amateurs and people who are trying to get voted in and trying to stay in power. I mean, this is a major medical problem that is not going to go away.

It's affected over one percent of our population, is going to kill over two hundred thousand, maybe three hundred thousand Americans when all is said and done. We need serious measures from serious smart people to know how to manage this. LTF, listen to Fauci. Use it, requote me on this, it's incredibly important. Go Tony.