RheumNow Podcast - Pandemic Numbers (4.3.20) Save

It's the 04/03/2020. This is the RheumNow podcast, and I'm doctor Jack Cush, executive editor of rheumnow.com. We're a month into this pandemic, and, boy, the numbers are sort of staggering. The information is changing almost daily. The concepts that we have to wrap our heads around continue to sort of blow our minds and challenge us as clinicians.

We're gonna review what we've learned in the last week. This week on the podcast, we're gonna feature a few new things. At the top, we're gonna talk about a town hall meeting that we had last night. This was a COVID town hall meeting for rheumatologists. I sent out an invitation to a few thousand rheumatologists and about 800 showed up to watch six panelists discuss the key issues surrounding the coronavirus and rheumatology.

Our panelists included Alvin Wells, Arti Kavanaugh, Alan Matsumoto, Kevin Winthrop, Cassie Calabrese, myself. We entertained a lot of questions, I think almost 50 questions between each other and the audience. It's an hour and twenty four minute broadcast. You can see it on the website. You can look at that site right there, our COVID nineteen update site, or you can look at it on our YouTube channel.

It's an hour and twenty four minutes. Settle in. It's jam packed with a lot of good informations. We tried to get to as many questions as we could. There are many more.

We'll try to address them this week. Also, on our update site is a nice video that you should look at from an infectious disease consultant, doctor Jade Lee here in Dallas. I asked Jade five questions about many issues including PPEs and masking, what to do with package deliveries, managing our room patients once they get infected, issues on testing, and how to work with your ID consultants. It's a good interview. Also, interview worth watching is my interview with Doctor.

Philip Robinson from the University of Queensland. Philip was one of the spearheading individuals behind this global rheumatology alliance and a very important registry where rheumatologists are entering their patients who have either proven or suspected coronavirus infections. The data at this point are very interesting. There's a 110 patients who've been enrolled, about thirty eight percent of them are rheumatoid, seventeen percent lupus, seventeen percent with psoriatic arthritis, seventy five percent are in remission, forty five percent are on biologics, twenty two percent were on hydroxychloroquine, there were five percent deaths. And interestingly, the patients on hydroxychloroquine were people getting sick and sometimes going to the ICU.

So there's a lot of questions that are gonna be answered by this registry. If you have a patient, you should go to room-covid.org. Room-covid.org to enter your patients and learn more about this evolving story. So what do we have to talk about? A few Twitter entries, think, that were very notable.

Eric Topol put up a Twitter feed that said The US death rates are doubling every two point six days, which means a hundred thousand deaths by April 11 to and two hundred thousand deaths by April 14. That could be underestimates. And the question is, are we gonna flatten the curve or not? And what are we going to do about it? You know, at the beginning of this week on Sunday, March 29, I put out the information.

There were a hundred and twenty three thousand cases of COVID Nineteen United States with two thousand one hundred and twelve deaths. Doctor Fauci on the weekend news suggested that there will be over a hundred thousand deaths, could be as much as two hundred thousand deaths, if we don't do something to flatten the curve. Again, that was 03/29. Here we are on four '3, and we already have over five thousand deaths. I saw one website last night that said it was over six thousand deaths.

In New York City, we're having five hundred to eight hundred new deaths daily, and the numbers are going up. This is scary stuff. We need to be armed with data, data that we can help manage this problem for our patients and for our society. There was a interesting tweet about the irrational use and coveting and hoarding of hydroxychloroquine during this pandemic. Obviously, it's inexcusable for anyone to covet or hoard hydroxychloroquine when patients who need it are gonna benefit from it.

That's our lupus patients, our rheumatoid, and the ones we've that have been on it for a long time. I think it's important to pause, think about this, and actually look at our video from last night from the town hall where we pretty much dispel any proof that hydroxychloroquine is the panacea for this pandemic. It is not. There's evidence that it may not work, and the evidence that works is based on an uncontrolled 26 patient study out of France. It's even weaker for the azithromycin story.

So clearly, who are ICU hospitalized on a respirator doing badly, yes, give them hydroxychloroquine. But for us to be stockpiling hydroxychloroquine to either prevent this infection, that would be goofy. To, give it to our to to people and family members so that they can self medicate, no, that's really bad. So, again, let's pause and think about this. So the question is, what can you do about biologics during, your the COVID disaster that we're dealing with, there's a lot of guidance, one from the Ontario Rheumatism Association, from the American Academy of Dermatology, even the ACR.

Don't stop your therapy, don't stop the biologic. Again, that may put patients at risk for inflammation, and those who are inflamed are the ones who are going to be immunosuppressed. There's a lot of ridiculous ideas out there that you got to stop, you know, the medicines that have been working for the patients and keeping them under control. It's not clear that you're immunosuppressing them. It's very clear that you're controlling inflammation in them and inflammation is highly damaging as we discussed last week.

So if you haven't seen the numbers, the numbers are repeated over the last few days that the number of cases in China, specifically in the Hubei province are down, And and there are no new cases in the epicenter of where this started, and life is returning to normal in that area. The the the shut ins and the lockdowns has stopped. People are out, traffic has resumed, people are working. They're still dealing with the aftermath of this infection, but life is changing, which does put an end in sight. But this is not going to be at the end of this month.

We're gonna peak sometime later this month with infections and deaths, so we need to be vigilant across the country. Everyone has to do their part. There have been a number of different actions by the FDA this week, some unrelated to this whole corona business. Lilly has Taltz, and actually that was approved by the FDA for use in pediatric patients with mild to moderate, I'm sorry, moderate to severe plaque psoriasis. The FDA also removed or strongly recommended the removal of ranitidine or Zantac from the market, due to its ongoing investigation with an impurity in there that really seems to get worse over time and with higher temperatures.

Zantac is gonna be off the market and for good reason. The FDA did approve over the weekend the investigational use of convalescent plasma in patients who have, gone through a COVID nine approving COVID nineteen infection. The use of convalescent plasma to treat people who are sick is really based on very little data, although there was a five patient trial that was reported in this last week's JAMA of people that were in respiratory failure on a ventilator, critically ill, high viral viral loads, not responding to other other therapies, and they were treated with steroids and convalescent sera, and three of them were discharged two weeks later. The other two were better, and recovering. So that's all in in important.

The The problem with convalescent sera, however, is that in other viral infections and other infections, it's not shown to work. It's often not doesn't work. So this is clearly experimental at this point. Speaking of experimental, on threethirty one, the FDA granted emergency use authorization for Chloroquine and Hydroxychloroquine in people who have the COVID nineteen infection. It is experimental, but they the FDA justified this saying that under the circumstances that there is enough data out there to authorize the emergency use of these agents in patients who may be sick.

They're not authorizing the use as a prophylaxis. It's in people who probably are hospitalized. As we talked about in some of the videos we did this week, it turns out that people who have this infection, eighty plus percent of patients who get this infection are gonna be mild to moderate symptoms, stay home, and you know what? They don't need to be treated. They don't necessarily need to receive hydroxychloroquine or azithromycin, definitely not azithromycin in my opinion.

But look at the video by the infectious disease specialist doctor Jade Lee, and that we discussed that there. The FDA also in issuing this emergency use authorization did put out a fact sheet for families and patients regarding the use of hydroxychloroquine, and that may be a useful resource for your clinic. There was a warning in Twitter this week about prolongation, QT prolongation in people who are taking antimalarial drugs, and that could be a serious unexpected side effects and it could be even potentiated azithromycin, but the cardiotoxicity of antimalarials is a rare event, and is often with use. Yes, the FDA has reported or there has been a report in France of death and cardiac problems from the use of chloroquine, and there are reports of cardiac deaths going back many years with chloroquine for the use of malarials, but for malaria. But again, these are rare events.

There are a lot of misconceptions about the safety of hydroxychloroquine and chloroquine. For most people, they're gonna be fairly well tolerated. There is no hyperkalemia associated with this. There are some cardiac and myopathy issues with this. We reviewed that and there's actually a daily download slide that you could look at the side effects and some of the concerns for the antimalarial drugs that are now in use.

So there are several questions now about the impact of comorbidities on outcomes with the corona infection. The CDC this weekend released an MMWR report on the impact of three specific conditions, coronary artery disease and heart disease, diabetes, and patients with chronic lung disease. Turns out that these conditions are across the board in The United States prevalent to the tune of about ten percent for diabetes, ten percent for heart disease, and six percent for COPD. They did an analysis of over a hundred and twenty two thousand infections. They had data on over seven thousand regarding the comorbidity issue and what it did to the ultimate outcomes.

The bottom line here is that patients who had those three comorbidities were more likely to be hospitalized and or be in the ICU than people who did not have them. So amongst non ICU hospitalizations, if you had a comorbidity, and again we're talking heart disease, lung disease, diabetes, you are more likely to be hospitalized, twenty eight percent, versus those that did not, seven percent. As looking at ICU admissions, they were more frequent, fourteen percent, if you had these medical conditions versus two percent in those without. This begs the question of our patients with rheumatic disease and the immunosuppressant and anti inflammatory biologic use. Are our patients at risk?

That's one of the big topics of discussion in our town hall meeting that you can look at. The bottom line is that there's a surprising paucity of our patients who are thus far affected, and have been hospitalizations. That is really the purpose behind the Global Rheumatology Alliance Registry and we hope to collect data and you should be adding to that information. We need to wait and see. Lastly, our last report is on universal masking with COVID.

This was a report in, the Thursday edition of RheumNow. It was also in this week's JAMA. It's been discussed by the CDC whether there should be more widespread use of masks for either patients or hospital workers. Hospital workers, it seems pretty clear. If you're on the front line, if you're interfacing with patients who are sick, possibly symptomatic, possibly infection or clearly infected, you need to be fully masked, gowned, etcetera.

It turns out that full universal masking is being recommended for screeners and people doing registration to come into clinic. This seems to be prudent. People who are dealing with patients who are hospitalized, they're being fully protected with masks and the full garb and gloves, etcetera. Really, the question though is should all health care workers be using masks or not? Should patients or people out in public be using masks or not?

Like, a month ago, I did a tweet saying it's not necessary. The recommendation is it doesn't work. And the truth is it doesn't work. There's a minimal return on the use of simple surgical masks or cloth masks or handkerchiefs over your mouth. It does cut down to a marginal amount, and a month ago that didn't seem to be important.

Now, it does seem to be important. So the New England Journal specifically talked about health care workers. It turns out that in China and Korea and Southeast Asia and many hospitals, it turns out that, masking is standard of care for frontline individuals, health care workers, and this is becoming a growing recommendation. The problem of course is that there's going to be problems with PPE, personal protective equipment shortages, and masks over time and especially in high dense densely infected areas like in New York right now. I think that healthcare workers should probably be wearing masks.

I wasn't wearing masks when this first started. I was advocating hand washing and wearing gloves. Now when I'm seeing patients, will mask and wear gloves. I don't need to use gowns. I think, again, frontline people, people who are going to be exposed to people who are infected, they should be doing masking and the full, you know, package which is, you know, hand washing, eye protection, gloves, gowns, and physical distancing for high risk individuals.

The rest of us, I think we should be wearing masks and gloves when dealing with the public. I think patients should wear masks when they come to clinic and they are symptomatic or infected. Now should we be using them out in public? Right now, it doesn't seem to be prudent, but I would not discourage it. It may provide a margin of protection that, could be beneficial given some of the numbers I quoted at the top of this broadcast.

I think that, the more you're around others or around large groups of people time wise, especially if you think they might be infected and you don't know, ten minutes or more, you might be wearing a mask out in public if you're a patient or someone's shopping in the store. That wouldn't be wrong at this point in this story of the pandemic of, twenty twenty. Why is it called COVID nineteen? Seems to be a big problem in 2020. Well, it started in 2019, but it's gonna go through the rest of this year at least.

That's it for this broadcast. Go to the website. You could check out the citations for the things we discussed today, and you can also find on our website the town hall meeting that was recorded last night. Tune in next week for more info.