RheumNow Podcast To Needle Or Not To Needle %2811.30.18%29 Save

This is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. It's the 11/30/2018. This podcast is brought to you by RheumNow Live.

When was the last time you went to a CME meeting and thought, wow. Or that you could easily, regularly, genuinely talk to the faculty during the meeting, during the lecture even, and in the breaks. And when was the last time you actually had access to all the meeting materials as downloads or electronically? RheumNow live is gonna happen in March 2019. You can go to rheumnow.live to read more about this meeting, but it's gonna be a neat, cool meeting.

It's for the better rheumatologist. It's in Fort Worth. It's gonna have a flipped classroom style of learning, short lectures, a lot of interaction between the faculty and the audience, a lot of Q and As and cases, TED like talks, streaming video, you'd really don't wanna miss this meeting. Again, it's for the better rheumatologist. And isn't that you?

So this week in the news, we have what? DMARDs that may actually lower infectious risk. How about a treatment for osteoarthritis that might make you smell? And lastly, to needle or not needle in carpal tunnel syndrome. At the top, we have a report from the VA Medical Centers talking about a serious problem in rheumatoid arthritis, that being one of chronic lung disease.

It actually occurred in a high percentage of patients in their very large cohort that they followed. Twenty one twenty seven percent of patients actually had evidence of chronic lung disease, and this increased the mortality risk significantly by as much as fifty percent. The sad part is that our therapies for rheumatoid arthritis did not alter these statistics. So use of methotrexate or biologics seems to have no effect on, what's gonna happen if you do get chronic lung disease suggesting this is a unique subset that merits more research, more attention, and newer therapies. Again, DMRs and biologics, especially TNF and head resolution shown not to really work in this subset.

An interesting study looked at ANCA associated vasculitis and showed that there were amongst almost two hundred patients, there were ninety five severe infections that amounted to about twenty six per one hundred patient years of exposure. What they showed was that the use of trimethoprim or or self and sulfamethoxazole Bactrim and a prophylaxis with Bactrim led to a reduction in the risk of severe infection by as much as seventy percent. Those who developed severe infections with ANCA associated vasculitis were those who are older, had evidence of bronchiectasis or endobronchial lesions and or COPD. We do know that again, this is a bad outcome. It's one that seems to be unique to these patients and it needs to be prophylaxed.

TMP SMX is a good option. There was another recent report that looked at what happened and again, ANCA associated vasculitis and showed again that Bactrim worked, but they also showed that there was an evidence for the use of hydroxychloroquine and antimalarials in the prevention of severe infections. They noted a number of studies that are out there that suggested that maybe you could actually achieve some benefit by using this. This comes from a lupus study, a thirty three thousand patient lupus study showed that use of hydroxychloroquine, reduced the risk of infection compared to those who never took hydroxychloroquine by, was twenty seven percent. Another study from Spain looked at three thousand six hundred patients with lupus and showed a smaller effect, but nonetheless a protective effect.

So again, amongst the many things that we know that hydroxychloroquine can do for our patients, maybe should be in the water, it should be in the Kool Aid for everyone because it may also protect against the risk of infection. More research I think is needed here. An interesting literature review looked at seropositivity in RA patients. We know that ACPAs and rheumatoid factor are important. Five, eighty percent of patients have those.

Being double positive is more important. There's a new antibody called anticarbamylated P antibodies that also seems to have the same predictive value. In this particular study, they showed that that if you were triple positive for ACPA rheumatoid factor and CAR p antibodies, it had incredible specificity, almost a 100% specificity, although finding all three was only seen, depending on how you measured it from eleven to thirty nine percent of patients. Suggesting that obviously doing rheumatoid factor and, CCP makes sense. Maybe we should be adding CAR P to that profile, once that becomes more widely available.

An interesting report, appeared, I think it was in Medscape from Ken Segg and colleagues looking at the safety of bisphosphonates. Again, a very important statistics that's quoted that you should keep in the back of your head because you talk about this with your patients, that is what is the risk of developing either osteonecrosis of the jaw or atypical femoral fractures. Atypical femoral fractures that's quoted in this particular report, one in a thousand is the risk. I'm sorry. One in a thousand is the risk for osteonecrosis wait.

No. Let look at the I'm sorry. You're right. Atypical femoral fracture is one in a thousand. The much more rare event is the osteocross of the jaw and that's one in about ten thousand.

And that other uses of other drugs like zolundronic acid, that up to a third of patients will have more commonly arthralgias and myalgias. But that one in a thousand to one in ten thousand is important statistic to quote to patients who are rushing to stop their bisphosphonate. That may be okay and drug holidays may be appropriate for some patients. However, if the patient has a much higher risk of developing a fracture from their osteoporosis, stopping the drug for these very rare events is to say quite simply idiotic. So again, I think you need to know those numbers when coaching your patients on how to best use their therapy.

I put up a tweet about TB testing, I'll go over this quickly. These are my guidelines based on expert guidelines. The bottom line is that everybody, should be, tested for PPD or, with a PPD or IGRA, QuantiFERON or TB, T SPOT, before the use of a TNF inhibitor and other biologics. If the patient is negative, then you can obviously start therapy. If the patient is positive, you have to evaluate for TB.

Do they have signs and symptoms? Do they have a negative chest X-ray? Can you culture either sputum or urine or anything else to look for evidence of an active infection? If it's negative, then they have LTBI and you can immediately proceed to, treat them while starting the biologic. You do not have to wait nine months or anything like that.

You can use both the same. Again, the wording in the package insert is it must be, LTBI prophylaxis must be started before, including two minutes before. If they have an indeterminate result, I tend to repeat the test and may even change the test from a QuantiFERON to an IGRA or to a tuberculin skin test. If it's the same, you can proceed and then watch and worry. If it's negative, you can go on and proceed.

Often many indeterminate results will turn negative after therapy is started suggesting, that it was related to inflammation much in the same way energy can be seen. You have to remember that up to 10 of patients who were initially PPD or IGRA negative after they get treated may show up to be either PPD positive or indeterminate QuantiFERON positive suggesting that they may have had latent TB that was disguised by their energy from their inflammation. Thus, patients who are starting on a biologic, especially a TNF inhibitor should have a repeat test done either three months after or when you switch from one drug to another to document that they did not have energy before. You'd be surprised. Again, the number, multiple studies, it's about seven to ten percent, you will see that.

But when you do see that, you have to make sure it is LTBI and not a new conversion, and therefore you have to look for signs of active TB. An interesting analysis again appears on a common issue that I keep repeating here, but it bears repeating, and that is a meta analysis of DMARD six studies, biologics five studies show no significant benefit when these agents are used in osteoarthritis. They are placebo basically. So again, we need other therapies for osteoarthritis. Good news comes in the form of, new data from the NRMP, the Residency Matching Program showing that rheumatology is actually one of the most competitive of fellowships two twenty one positions and three thirteen applicants in 2018.

Two thirds of these were filled by US grads, one third by foreign grads. Commentary by David Karp from UT Southwestern says it looks like it's going to be the same for 2019, the numbers are staying up, it's getting competitive. We need funding to expand our fellowship positions so that we can meet the unmet need of loss of a workforce which is going to occur soon. I want to remind you and we did so in a Twitter report that there are six FDA approved TNF inhibitor biosimilars in The United States. Three for infliximab, that's Effixi, Renflexis, and Inflectra.

There are two for adalimumab, that's Amjaveta and Cytelzo, Seltelzo, and one for etanercept, and that's Aralzi. Interestingly, this past week, rituximab, a biosimilar rituximab was also approved, but only for use in non Hodgkin's lymphoma. They did not get the other indications, that we have for, Rituxan including in vasculitis and pemphigus and, in rheumatoid arthritis. An interesting study of overweight and obese, individuals, elderly individuals who had knee osteoarthritis in a double blind randomized placebo controlled trial when given garlic actually showed significantly lower pain scores, lower resistant levels, and better outcomes. They also measured TNF levels that did not change with this, herb, if you will.

But nonetheless, it's curious that maybe your patients who are taking garlic may be getting some benefit from it. There is some weak research showing that garlic may have an effect on metalloproteinases and maybe on cytokines like resistant. It has been shown to lower CRP levels in some patients suggesting this like some of the other ones we've talked about recently, including frankincense and others may have some benefit in our patients with osteoarthritis. We had a nice report on the use of steroid injections in individuals, who have carpal tunnel syndrome. This was actually a two thirty four patient open label sort of pragmatic trial where patients were randomized to receive either a twenty milligram methylprednisolone acetate injection into the carpal tunnel, done clinically not with ultrasound guidance or anything, or they were randomized to night splinting, and the outcome measure was at six weeks.

There's an actual tool for this called the Boston Carpal Tunnel Questionnaire, the BCTQ. And while the vast majority of patients completed the trial, the BCTQ scores were lower for those who received the injection. I don't know if it was gigantically lower, it looked it was significant and and statistically, it looks like it's possibly clinically meaningful. I often am faced with, do you want the injection now? Do you wanna try splinting and do this conservatively?

Usually, the decision is made by the weenies that don't wanna have an injection. But clearly, maybe this data suggests that you should do the injection because patients might fare better. Then our last report is on the Aura trial. This is a trial of voclosporin, a calcineurin inhibitor in patients with lupus nephritis. This data was presented at prior big meetings like, EULAR and ACR.

Two sixty five patients with active lupus nephritis were randomized to receive one of two different doses of voclosporin versus placebo. And the complete renal response was seen in only nineteen percent of patients on placebo, but twenty seven-thirty two percent on voclosporin actually turns out the higher response was seen with the lower dose of voclosporin. Again, the side effects were roughly about the same or a few more deaths in that low dose voclosporin group. Again, lupus nephritis, trials are going to be riddled with a lot of serious adverse events because of the use of steroids and lupus and whatnot, and also having nephritis. But nonetheless, I think this is very encouraging data and very clear data showing that voclosporin is going to be a contender, in the lupus treatment world, we need to see further studies.

Remember, the anifrolimab studies which look great in phase two, earlier this year reported their phase three trial didn't work. So it's very difficult to do lupus trials and to prove efficacy because patients are highly complex, they have multiple comorbidities, multiple therapies, the outcome measures are arguable. I think this approach that they've taken with voclosporin going after a subset of lupus patients, the nephritis patients as opposed to trying to get a whole indication for lupus, this makes more sense than trying to get a whole indication looking at SLEET I2K or SRI4 responses. Anyway, that's it for this week at RheumNow. Go to the website, you can click on the links to find out more about these specific reports.

Again, you can go to roomnow.live to learn about our exciting meeting in March 2019. Artie Cavanaugh and I are hosting that meeting, you won't be disappointed. We'll see you next week, bye.