RheumNow Podcast New World Order (3.27.20) Save

It's the 03/27/2020. This is the RheumNow podcast. I'm doctor Jack Cush, executive editor of roomnow.com, and it's a whole new world out there. Learning to deal with normal, the new normal, the future normal is gonna be difficult, and we're here to cover the news and cover COVID for you. I wanna give you some of the highlights from the past week and some things to think about for next week going forward.

You'll notice on our weekly feed on our, on our website and also now on our, daily email, we have a feature box that says RheumNow coverage of COVID, 2019. You can go on there. You can find the resources I'm going to mention today, news articles, tweets, and videos that may be helpful to you or helpful to your patients. I specifically want to draw your attention to PSAs. Those are, we call them patient service announcements.

For patients, in dealing with COVID. We did five videos on this, and they're up there, PSA one, two, three, and four. And they basically discuss, managing your medicines, what to continue, what to stop, how to manage that, managing your medical care, safety advice on how to avoid COVID, myths surrounding COVID, and the last one we just posted today on dealing with stress. I think you'll find these, to be valuable resources for your patients, if not you. These will all be made, available as a compiled podcast, and hence, it'll be about thirty, forty minutes.

You can look for that on your podcast channel. We posted a few interesting pieces of information that you should look at. One was, we have a slide on, the side effects of, hydroxychloroquine that's posted. And also, we have a tweet that basically says, you know, Chloroquine side effects are basically equal to hydroxychloroquine side effects as far as retinopathy, and other things. It's just that it's more and tends to be more severe.

Side effects associated with Chloroquine include not just the retinopathy and maculopathy, but also cardiac issues, prolongation of the QT interval, conduction disturbances, overt cases of CHF have all been described. Ototoxicity, I wasn't aware of this, but hearing loss, balance issues, and tinnitus, not uncommon, about six to seven percent. Rashes we know about, itchy rashes are pretty quite uncommon. Frank urticaria is not usually part of what you see with the antimalarials, but they can get hyperpigmented, photodynamic reactions. And then there's some issues with regard to psychiatric disease in some people, and you wonder if that's because of preexisting disease or whether that's new from the medicine.

We do know that the antimalarials can worsen psoriasis and they can worsen porphyria in some patients, but can't remember the last time I saw a porphyria patient. Anyway, these are on the website for you to look at. There's a nice report, I believe, out of Japan that looked at the comparative in vitro efficacy of chloroquine and hydroxychloroquine against the SARS CoV, CoV two or the coronavirus infection, looking at in vitro outcomes showing that, they're both very effective. And then at the end of the article, they talk about hydroxychloroquine being more, effective, but that's really on the supposition that hydroxychloroquine tends to be safer clinically, not because it was more effective in vitro. The ACR came out with a nice video, Ellen Gravelis.

You can look at that, the ACR website. On our site, we have it as well, giving you some background of what the ACR is working on, that the committees are working on. And I think that that's comforting to know the ACR is on top of this. Also on top of this is the American Academy of Dermatology that actually issued a paper guidance on dealing with COVID and infections. Right up front, say, number one, do not stop biologic therapy without talking to your doctor.

Number two, for those who have, proven COVID infection, yes, you should probably stop your biologic, but also talk to your doctor. But you have to have a proven COVID infection, not a suspected. For those of you who are without COVID symptoms, or without a positive test, do not stop your medicine in spite of all the warnings that you may be at higher risk or people on biologics are higher risk. Again, I've told most of my patients you're not at higher risk because you're not immunosuppressed by most of the medicines I'm using. You know, TNF inhibitors, IL-seventeen inhibitors, IL-one inhibitors, or, you know, abetacet.

If you're using those drugs to control inflammation, you've gotten rid of the number one cause of immunosuppression, which is inflammation. That's your number one cause of immunosuppression, and hence you've tilted the balance back towards normal. So these patients should not be running around thinking that they're all immunosuppressed and horribly at risk. I think if they're very sick and been in the hospital a number of times, and their disease is totally out of control and they're on multiple medicines, again, it's the disease out of control that puts them at risk. It's the high doses of steroids that puts them at risk.

So these American Academy of Dermatology recommendations, think, are prudent. If you haven't seen Michele Petrie's video on dealing with hydroxychloroquine, and the potential shortage, you should see it. It's on our website. It's been viewed by over a thousand people already. So I think it's a telltale.

I think you should know about a few sources that you could follow on Twitter. One would be EBMRoom at EBMRoom, which is Doctor. Mike Putman from Northwestern. He has a nice discussion on this hydroxychloroquine azithromycin study that was done in France. And he basically says that there are some pitfalls in this COVID study.

Number one, it was not a randomized trial. It was an open label treatment of 26 patients, not all of whom, actually received, both therapies. All of them received hydroxychloroquine and only a portion of them had, the antibiotic added on top of it and without any well or clear description as to how that happened. There was no clear outcome other than reported that a bunch of patients got better and that was even good. The control arm was ill conceived and they had patients that were dropped from the analysis and they overstated their conclusions, about this.

So again, everyone's pointing to this French study as the reason why hydroxychloroquine, everyone needs to be on it. Again, positive reports get overblown, but we need a good study and we need more repeat research. You know that CMS has relaxed a lot of its guidelines on coding for telehealth visits. The office inspector general has said that the ninety day moratorium on sanctions for anyone who's going to waive co pays and cost sharing obligations for those in federally funded programs like Medicare, Medicaid, etcetera. So the government's working with us to provide for excellent care in this time when all the rules have changed.

Many agencies have signed on to the Global Rheumatology Alliance, is studying the COVID nineteen infection. This was started by doctor Philip Robinson from Australia and doctor Janusz Yadazni and others from UCSF. A a group of 12 people started it. Now there's hundreds of people supporting it. The idea is that UCSF is housing an IRB approved registry, for rheum patients who have COVID-nineteen infections.

We have the links, on our website for you to sign up and enter your patients. And I think it's an important thing that we have to do because right now we're dealing with a whole lot of I don't know and shrugs because we don't have data. This is the best way to get real time data. And if this is done worldwide by all rheumatologists, then we're gonna have some real data and information that's gonna guide us in the next few months. We have a lot of good videos this week.

You know, most of our content usually is written content plus, Twitter content. We got a lot of good videos. Cassie and Len Calabrese from the Cleveland Clinic talking about, the viral load, how that changes, what it means as far as symptomatology, and and maybe how it should guide us in choosing therapy. Michele Petrie, a great video on hydroxychloroquine. Arti Cavanaugh on don't stop, not the Fleetwood Mac song, but why you shouldn't stop your therapies, especially if, you know, you think your patients may or may not be doing well.

There's a real downside to stopping medicines. Catherine Dow, my partner talking about adjustments in practice, which are real. Eric Werderman telling you about the guidelines that they put in place at Northwestern on how to handle infusions. Kevin, Winthrop at, Oregon Health and Science Center talking about managing infection and some wisdom from a true ID expert. Alan Gravelis from the ACR.

And we have three videos from Alvin Wells. It's a triple play talking about telemedicine and how you can stay connected with your patients remotely. So the bottom line here is the world has changed. You need to change. And while change is difficult, change should be good.

This is gonna probably lead to new ways in which we conduct our business. We all need to be on board. We all need to work at this. Not changing is gonna be a disaster for you and your patients. So please get on board.

You either need to lead or you need to be led. Find people that you can latch onto who have the information. I think, for instance, it's kinda goofy to listen to a bunch of political people talk about the COVID infection when they don't know what the heck they're talking about. On the other hand, talking to or listening to Anthony Fauci when he gets to the microphone is smart. I mean, the guy knows and he's leading.

Follow his lead. Likewise, our medical, centers and their leaders who are dealing with this on the front lines, we need to listen to them as well. I'm gonna end with some things that we don't yet know about and this is what we need to work at. So, number one, are our patients at higher risk? We're told that they're, you know, if they're older and they got immune diseases and immunosuppressives and, you know, if that's the case, you know, we would have heard a lot of disastrous reports about this from China and Italy and Germany and Seattle where this started and now in New York, and we're not hearing that.

We're hearing that a lot of people are affected by this virus, that maybe the worst outcomes are in the elderly, but boy, there's a lot of young people who are in the ICU. There's a lot of 50, 60 year old men with no preexisting conditions who are developing rapid respiratory failure and crapping out, and we don't know why that is. This bug is an equal opportunity offender and we need to realize that. Which is to say that I'm worried about my patients but I'm also giving them a little bit of hope saying we would have heard a lot of bad news by now and I know that we need data and that's why you need to join the COVID Rheumatology Registry which you can get on our website. Next, what are we gonna do when hydroxychloroquine and the IL-six inhibitors are in short supply?

So we're already hearing about doctors and healthcare workers, dentists writing prescriptions for hydroxychloroquine for themselves and their family. Are you kidding me? Pharmacy is calling me saying, do your patients really need to be on this because we need to stockpile this drug for people who really need it? No. My patients with lupus and rheumatoid arthritis really need it.

It's proven to work. It's proven to save lives. It's proven to avert renal failure and hospitalizations. We to fend for our patients and their right to continue on hydroxychloroquine and the IL-six inhibitors. If you're on an IL-six inhibitor, I hope you're on it for a good reason.

Not because, well, let's just add it because it might no. It's actually working. And if it's not working, get off of it. So we need a strategy. You know, I think one easy strategy for hydroxychloroquine is to make the switch to chloroquine.

Four hundred milligrams of hydroxychloroquine is equal to two hundred fifty milligrams of chloroquine. You need to watch them closer, you because you haven't used the drug very much. Get more regular labs. Get more frequent eye exams. And, yeah, it's gonna work out fine if we have to do that.

I would use azathioprine or, because I don't think that's very immunosuppressive at the doses we use, and I think you can control a lot of skin disease, with azathioprine. If you can't get IL-six inhibitors, then use another biologic or other therapies. I'm a little miffed at the reports from my pharmacy saying, last week, can we not use that IL-six inhibitor or do those IL-six infusions in those patients because we're gonna need that? And I yelled at them and said, no. This week, they're telling my patients we can't do the infusion.

So they're not listening to me. They're gonna take IL-six away from my patients and that is a bad move. We got enough badness running around without pharmacists who don't know what they're doing here or political people or administrators think they're doing the right thing, work on getting PPEs and respirators and hospital beds. Don't worry so much about hydroxychloroquine and IL-six shortages. I don't know, I mean, I want them to be available for patients, but we have many more patients with arthritis as well.

You are on the front line of negotiating who will and who will not get these drugs. Third big question, what is the scenario and the sequence, that will ensue when one of our patients calls with a fever of 102 and respiratory symptoms? What are you going to tell them? What's the best medical advice? Number one, you write the letter or the prescription and they go and get tested.

But now you've got a two to five day period before you'll hear about the results of that test. What are you going to do? You need a plan. I would say number one, isolate. Number two, get them an an an n 95 mask and tell them if they have to be around family or children or friends, they have to wear the mask and keep their distance, but then go back into their room and stay there until we know what what the heck to do with them.

We can manage them symptomatically, and yes, you can use acetaminophen and nonsteroidals. The French government was goofy in their in their directive, which is not based on any fact. It seemed like a good idea. And then, when they get, you know, infected, what are you gonna do with their therapies? You know, if they're on hydroxychloroquine, baricitinib, and an IL-six inhibitor, well, it, and then let's treat what else may need to be treated and work with an infectious disease specialist on this.

But I think we want to see a more clear cut plan for when that happens. And lastly, where are the positive stories from lessons learned in, China and in other countries, or in New York City right now based on disasters? So when disasters happen and bad things happen, guess what? You get disaster plans and preparedness training. We're going through that right now, but we need to learn from those experiences.

And, again, we wanna know the examples of where those disasters were avoided and how. What was it that happened that these other patients didn't get infected when those patients did get infected? These are the stories we're looking for in going forward. Follow us on RheumNow. We aim to help.