RheumNow Podcast - Preaching To The Choir (5.22.20) Save

It's the 05/22/2020. This is the Room Now podcast. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This week on the podcast, women dominate in rheumatology, but not necessarily in salary.

What's the downside of COVID, you ask? Beyond the financial? We know. And when can you finally go back to church and throw away the mask? Well, I think I have an answer for you.

We're gonna start with an interesting study from annals of rheumatic disease. I thought it was interesting because I always thought Behcet's disease was sort of a struggle with colchicine. Doesn't work in my hands. Worry about steroids, works, but gosh, too toxic. And thank goodness for the approval of a premilast.

Well, this report was an uncontrolled study of 15 patients with refractory Behcet's who were treated with, that's right, the IL-seventeen inhibitor, secukinumab. Now there is some biologic rationale for this, and IL-twelve twenty three's have been talked about, and IL-seventeen's been talked about, IL-one inhibitors have been talked about. Well, in this small pilot study of 15 patients, two thirds of the patients had a complete response when they were given secukinumab. Now they largely improved with regard to their mucosal manifestations and their articular disease, But, gee, it looked pretty darn good. And if you follow them out and that that that by the way, two thirds, nine out of fifteen was within three months.

If you follow them out to six months, eighty seven percent of patients improved. So they either received a hundred and fifty or three hundred milligrams a month. I think it's encouraging. Again, this would be off label use, and whether or not you can get away with that is sort of up to where you are and and what you've been through. I think it's encouraging.

Voltaren gel. What do you think? Is it real? Should we worry about it? Should we use it?

The great thing is it's a safe operation. I mean, I think why not use it, but, does it work? Well, the FDA just about a month ago, approved the over the counter availability of diclofenac topical or Voltaren gel. This new preparation is called Voltaren Arthritis Pain. It's topical nonsteroidal.

You know, that the drug was actually approved first in 2007 for the pain of osteoarthritis, and it's now available over the counter. My own belief is it doesn't really work all that much. I'll try it, but, you know, for the one in five that respond that respond to it, great. The good news is it's not toxic at all. So I looked up some of the numbers on efficacy and the number needed to treat is about five as much as nine.

That means you gotta treat five people before one gets a clear cut advantage or nine before one gets a clear cut advantage. It's about in line with what I see in my practice. The number needed to harm is thankfully about one in fifty or the NH is fifty. So that suggested it's fairly safe. It's out there.

Congratulations. Two studies on Still's disease I think that are interesting. One was from Annals Rheumatic Disease, an uncontrolled fourteen patient report of patients who met Yamaguchi criteria for adult Still's disease who had refractory disease, and they were treated with tofacitinib. Now we've hinted before that JAK inhibitors may be helpful in Still's disease in kids or in the MAS associated with Still's disease. In this particular study of 14 patients, seven out of fourteen half had a complete response and six out of fourteen had a partial response.

It seems like this might be a reasonable option, and we need to see clinical trials, well designed clinical trials. The problem is doing clinical trials in Still's disease, I can't imagine any of the manufacturers of JAK inhibitor will go after this, but it would be a good orphan drug indication in my opinion. There's another interesting study from clinical rheumatology that mirrors some other data that's out there. Their study was on patients with, Still's disease, mostly these were kids, fifty seven kids with systemic JIA and they actually did some gene testing and showed that there was a fair number of patients that actually had the MEF Phe gene associated with familial Mediterranean fever, variant, and having that actually increase the odds of getting Still's disease. So the idea here is that there are some patients who have clear cut Still's disease, but if you did gene testing on them, you might find some of the other auto inflammatory genes that, are out there.

And the question is, is it worth doing? I don't know it's worth doing. It's kinda hard to get. But if you can do gene testing and your patient has atypical stills, either in a kid or adult, I would thoroughly encourage you to do gene testing and look into Invitae, invitae,.com. You can get a cash, gene profile for as little as 75 to $100.

Patient pays. You get the results fairly quickly. It might figure well into your management or diagnosis of someone who has a febrile disorder. There was a recent JAK inhibitor safety review, and this actually comes from the GI literature, gastroenterology. And they looked at a meta analysis of 82 studies, sixty six thousand patients with either RA, IBD, psoriasis, psoriatic arthritis or AS and showed pretty good numbers.

No mortality risk, showed that the risk of an SIE is, you know, fairly reasonable. Not to not what is it now? The SIE number is two point eight one per one hundred patient years and the risk of herpes zoster is a little bit lower than that's been the literature before and that is a two point six seven per one hundred patient years. Again, your risk, you out there, is about five to ten per thousand. That would be point five to one point o per one hundred patient years.

Early data on JAK inhibitor associated zoster events were as high as forty five per thousand, but seemed to be lower if you did some pairing down according to, you know, a US population, mostly white, not on steroids, could be as low as twenty five. That's what this number is, twenty five per thousand or two point six seven per 100 patient years. Overall, it showed that JAK inhibitors were associated with about a fifty seven percent increase in the risk of zoster, a relative risk of one point five seven. Women in specialties, in medicine, well, turns out the highest percentage of women in medicine is seen in OBGYN, fifty eight percent. Pediatrics, fifty nine percent.

Third on the list, rheumatology. Fifty four percent of of trainees going into rheumatology are women, and that's good news. The interesting thing is that still when you look at just specialty medicine, men still make about 31% more than women with an average salary of 375,000 compared to 286,000 in women. These numbers come from the recently published Medscape profile on salaries and income in medicine. You can look that up.

It's in the link that we have associated with this particular report that I focus just on women. I put up another report this week about critically ill rheumatic disease patients, patients who go into the ICU and what their outcomes are. You know, I don't really like studies like this. It's kind of a hodgepodge, although the numbers are large, five twenty five critically ill patients, but includes twenty five percent with vasculitis, twenty two percent with lupus, nineteen percent with RA, etcetera. You know?

But I still think it might be worth reviewing the data. They were admitted to the ICU with either shock, forty one percent, respiratory failure, thirty two percent, infection almost forty percent, disease flares thirty five percent. Predictors of mortality were age, steroids, mechanical ventilation. So for those of you who don't go to the hospital very much, these are the factors that you might need to worry about your patients being older on steroids who end up being intubated, a good outcome. You know, how does this compare to what we're seeing now with COVID?

The real bad predictors for critical outcomes with COVID still age, comorbidity, the presence of high IL-six levels, presence of D dimers have recently been shown to be significant risk factors. We published that based on a New York City experience of those who had COVID and had critically ill disease and were hospitalized at two New York City hospitals. So what else is going on with COVID? What are the effects of COVID? Well, a Medscape survey showed that there's been about a 55% drop in revenue with COVID and that there's been about a sixty percent drop in patient volume.

Maybe more scary is that forty four thousand, 40 three thousand healthcare workers were laid off in March and that nine percent of medical practices closed during the COVID era. This is sort of scary. This is the downside that we're going to see more of in the months to come and how we are going to deal with it as a specialty is going to be a challenge. We need novel thinking. If you have a good solution, you should share it, write an article about it, publish it, do some research on it.

Other downsides to COVID came out in yesterday's New England Journal, where they talked about myocardial infarction hospitalization rates during the COVID era. So they compared hospitalizations for myocardial infarctions to hospitalization rates prior to March and showed that during the COVID era, MI hospitalization rates are down about forty percent. And that's sort of scary, but this is going to a conversation that you're hearing more of. What's the downside of being shut down and locked down where people are not leaving their homes and not going in for routine medical care or even worse, life saving medical care, like myocardial infarctions or chemotherapy or cancer management or breast cancer management. Even dental care is way, way down right now and what the cost of society is going to be to control these other problems and during the COVID era is going to be kind of scary.

So, you know, and the other interesting thing you might have heard this week during the Tuesday night rheumatology with, Peter Nash and, Philip Robinson from Australia talking about even though the numbers of COVID, infections and deaths in Australia are very, very low. We have more in Texas than they have in, Australia. The effect on their society has been pretty much the effect like it's been with you, as it's been with me, as it is in New York City. Everybody's not going out, everybody's following the rules, practices have been tremendously impacted, everyone switched to telemedicine, even in places where again, COVID is not that big a deal like it is in New York City for instance. So again, we need to be thinking along these lines about the other downstream effects of COVID.

And CDC put out an interesting report this week in MMWR about, 92 attendees in an Arkansas church during a month of, during March, that 38 of those ninety two people developed laboratory confirmed COVID infection. Three people died. The highest attack rates were in, the elderly, over fifty percent. So this data is a little bit like what we reported last week, where we talked about choir practice, 61 people and fifty three to eighty seven percent of people became COVID positive, three hospitalized, two died. Point being, getting together in groups, especially singing groups or people mouthing off or yelling, like, at sporting events might be still a hazardous thing, to consider as everyone's trying to open up.

I put out a tweet this week because I've been reading a lot about the hoaxes and conspiracy theories about COVID. This is not a conspiracy. This is not a hoax. This is not, you know, the man on the moon, nine eleven hoaxes that people like to write about. Again, the problem with these kind of con conspiracy theories is that you really they're falsehoods that you really can't disprove.

They're based on a modicum of facts. There's a video out there called the Plandemic. It it's a it's a total hoax, but it tries to question, the COVID nineteen crisis and the people behind it as being those who will capitalize on this financially. We have ninety three thousand deaths from COVID nineteen right now in The United States, and that's in less than three months. This is not a coax, folks.

I think people still need to be vigilant in their practices such as, you know, social distancing, physical distancing, hand washing, and wearing masks. I don't know if you saw the report, this week from New York, governor Cuomo said, you know what, wearing PPEs does work because evidence comes from frontline workers, the essential workers in New York City and New York State where those individuals, nurses, firemen, EMTs, the police force, transit workers, all who are practicing with PPE's and not like, you know, full garb and whatnot, just masks for the most part, that they have lower rates of COVID positivity than does the general population in either New York City or New York State. So for instance, NYPD positivity rates are ten point five percent, EMTs and fire departments seventeen percent, but almost twenty percent of the of the New York population is COVID positive on recent testing. So again, these are data that you can point to for those who are saying, ah, it doesn't work or oh, I don't really need it. It does work, and should be strongly advocated until this whole problem has gone away.

Lastly, there's a report that, we tweeted last week, we published this week about the use of Anakinra in patients with severe pulmonary COVID. This was a consecutive patient study. It was published in Lancet Rheumatology. Twenty nine patients who received anakinra consecutively for the treatment of non ICU, but nonetheless, pulmonary, severe pulmonary ARDS with COVID. They were on background therapies, twenty nine received anakinra.

They compared them historically to seventeen patients who did not receive, anakinra and the outcomes were strongly in favor of anakinra. So it's a fairly loosely, loosely controlled study, but it showed that deaths were only ten percent with anakinra, forty four percent in the control group that improved CRP and pulmonary function seen in seventy two percent of the anakinra treated patients, but only fifty percent of the control group suggesting that there is a good rationale to using IL-one inhibitors in patients with severe disease. Again, there's some anecdotal evidence so far about the use of IL-one inhibitors and IL-six inhibitors and baricitinib. We don't have the control clinical trial data. Moreover, we don't have data, of these interventions in patients where it's really needed the most.

And that would include those with the cytokine storm syndrome. But again, those trials are in progress. We'll look forward to seeing them. Speaking of cytokine storm syndrome, next week's Tuesday night rheumatology grand round series features, doctor Randy Kron, who is really well known for his work in MAS and cytokine storm syndrome. He's gonna be talking about the cytokine storm.

Randy's from University of Alabama, Birmingham. He's got a number of publications on this, topic. I think it's gonna be a real interesting hour. That's Tuesday night, 8PM eastern, 7PM central, 5PM PST. Make sure you register.

Tune in. We'll be we'll a really lively q and a session with doctor Cron. That's it for this week on the podcast. Go to the website. You can find these links, to these interesting reports and more.

Take care of yourselves. Take care of your families. Take care.