RheumNow Podcast When Youre Hot Youre Hot (10.11.19) Save

It's the 10/11/2019. This is the RheumNow podcast, and I'm doctor Jack Cush, executive editor of rheumnow.com. This week, we're gonna talk about a few interesting things, like when you're hot, you're hot and may be easier to treat, or the good, bad, and squirmy behind drug spacing. And lastly, why do we stink at gout? Or do we?

So we'll start with a really rare disease, pigmented villanodular synovitis. I diagnosed one this week. I'm expecting a bonus in my pay. It's like the third one I've seen in my whole career. Interesting benign tumor happens mostly in knees, but you know what?

Actually, happens in other joints too, TMJ, elbow, hip, ankle. It's been described in a lot of different joints. So therefore, you should consider it in someone who has a chronic, monarthritis, usually not too inflammatory. And when you stick that needle in, you may get out a bloody looking kind of effusion. Of course, it wouldn't be from blood because you're good at sticking needles in joints.

But obviously the diagnosis is made by either MRI, where all that iron pigment that's in that joint shows up as black, black, black on MR, or by tissue biopsy. Turns out that the only treatment for this appears to be excision. They've experimented with radiation and a few other things, but local excision seems to be the way to go. A nice report comes from the ASBMR meeting, that's the Bone and Mineral Metabolism People, where they actually had a nice report that was presented this past week on patients who were taking the anti sclerostin drug, Romecizumab. As you know, this was recently approved for postmenopausal osteoporosis.

In this particular study, they add a new caveat to management, and that is patients who have renal disease and renal insufficiency appear to be able to take Romecizumab without any particular risk. Now, their patients that they looked at were patients, who you would expect had benefit as far as fracture risk in hip and spine and femoral neck, and improved with Rumbilizumab. But there was no downside when patients had mild to moderate renal impairment. They actually had too few patients, like zero point nine percent or something of the patient group that they looked at were in that severe renal, impairment group. So there's no conclusions to be made there.

Osteoarthritis, a big concern of ours. We make the diagnosis all the time. We'd like to prognosticate on that. We'd like to be master clinicians. And a really nice study comes from the osteoarthritis initiative telling us that the bulge sign, you know, the sign you would do to squeeze the fluid up to the suprapatellar pouch and then you touch on it and everything kind of slides to, the side showing you a bulge that appears indicating mobile fluid.

You need at least a 100 cc's to see a bulge sign. They compared certain clinical findings in over four thousand patients with knee osteoarthritis and showed that the patellar tap, not so good. It was only seen in about two percent of patients. They found the bulge sign in almost thirteen percent of patients. And they showed that, having the bulge sign increased the odds of actually having more frequent knee pain by thirty one percent, by fifty percent, the odds of actually needing a future knee replacement.

So, sort of interesting, clinical finding that, sort of reaffirms those great clinical skills that you don't get to use often enough. A nice sort of sub study comes from the AVERT trial. If you remember, the AVERT trial was a study of abatacep in patients who had very early RA. This particular study, they looked at the utility of MRI and MRI findings, specifically inflammation on MRI. And in the two twenty five patients they studied, nearly half or forty four percent had elevated MRI inflammation at baseline.

And when they looked at what happened to those patients, it was clear that patients were randomized to receive either Avitas and methotrexate or just methotrexate. It was clear that the combination patients, the combination group responded best in the group that had MRI inflammation at baseline. If they didn't have MRI inflammation or just a low amount of that, it turns out that it didn't seem to matter whether they got methotrexate or the combination of apatasib and methotrexate, suggesting when you're hot, you're hot, and you have more room to improve on these objective measures like CDI, SDI, DAS remission, etcetera. So, it's not surprising that the patients who respond best are the patients who are most inflamed. Will they all get to the same level of achievement?

It's hard to say from this one study, but it sort of reaffirms that more aggressive disease should get more aggressive management. A nice study comes on the use of Actemra and what you can do with it as far as spacing the drug out. We've got tons of studies looking at, either drug withdrawal, drug cessation over time after achieving remission, spacing out the dosing to take, a half or a quarter and whatnot. So this particular study of one hundred and seventy nine RA patients looked at the ability to achieve remission when either they continued their weekly tocilizumab or they went to every two weeks. So the good news is that, seventy three percent of patients who went to every two weeks still stayed in remission.

The bad news is that if you stayed on a weekly drug, ninety percent would have stayed in remission. So that's the good and the bad. And if your patient is motivated or you're motivated, the odds are still pretty good the patient can maintain remission. I think, again, the bottom line is when patient achieves remission, you might lessen therapy, but the guidelines and many studies show that withdrawing therapy is just plain idiotic and destined to be met with recurrence of disease. Lenny Calabrese on Twitter just yesterday put out, an interesting tweet that said, Why do we take such crappy care of our patients with gout?

Is it because we have such divergent guidelines or are we just overwhelmed? He asked, Your take, please. Of course, I jumped right in. My response was, It's sacrilegious, but true. Sacrilegious to say that even us, the experts of gout, rheumatologists might not be good at gout.

It's actually true. We're not as good as we think we are. Certainly, we know that primary care, ED physicians, all others are just horrible at managing gout. The question is, why do we think we're so good at it and why are we not? Well, my answer was all of us think we know gout and all of us think we know how to manage gout because we learned it in medical school.

It was reinforced in probably all the wrong ways in residency. And now we just see too few patients to really be good at it. I think that might be a major factor. The other factors are, you know, we don't believe in guidelines. Guidelines are for suckers.

It's for other people who don't know what they're doing. And then lastly, the vast majority, hopefully not rheumatologists, but the vast majority of the world thinks, Hey, it's either colchicine or allopurinol, and voila, I'm great at managing gout, when in fact that's not even close to being true. We fail as rheumatologists because all your patients are on three hundred milligrams a day. No one's on higher doses, but yet nobody's actually achieving treat to target. Forty to sixty percent of patients even treated by rheumatologists achieve treat to target.

Could be the patient's fault, but you got to take your responsibility too. I think the other issues here is that other physicians, but even rheumatologists, don't monitor, hence you're not able to get to treat to target. We tend to undertreat, that I just mentioned. We tend to still use allopurinol three hundred milligrams or colchicine, when there are other ways of treating this disease and being more aggressive. A lot of comments from others on Twitter and talking mainly about how bad internists are without taking any ownership of how we may not be doing good.

Someone wisely pointed out that the best studies on this actually come from treat to target protocols run by nurses or pharmacists who manage treatment according to a protocol. And guess what? They are way better than you, the average rheumatologist. Someone mistakenly had some issue in here about, allopurinol dosing based on creatinine clearance. The whole idea of adjusting allopurinol to the right creatinine is gigantically overblown.

You can almost use allopurinol at any dose you want as long as you monitor the creatinine. So patients with a creatinine of two or even three can still get two hundred, three hundred, five hundred milligrams, four fifty milligrams of allopurinol. You just have to monitor. It's really the colchicine that clearly needs to be dosed according to creatinine clearance. And lastly, we should be using EMRs to make us all smarter or all held to a common standard in the management of gout.

A nice study comes from a group that looked at what happens when you use treat to target in lupus nephritis. And what is your goal? Well, in this particular study, they looked at 87 patients who had class three and class four lupus nephritis and compared the usual goal of low or no creatinine, achieving a urine protein creatinine ratio of less than 0.5. And those patients did well. But they said, what if you were more stringent?

What if we went for better levels of improvement? And let's move that urine protein creatinine ratio down to 0.15 or less. Are the outcomes better? Turns out it was more stringent criteria for success, has lower renal flare rates, less overall development of CKD, and more mycophenolate use, suggesting being stringent is probably being better. We reported last week, but didn't talk about it here, about a New Zealand study about the cost of OA.

In 2013 in the country of New Zealand, the cost of knee OA was about $200,000,000, And they project that by, 2038, it's going to go up to $370,000,000 The real question here is why is it going up when treatment isn't really changing? Meaning there's no new drugs on the horizon that are going to increase the cost like we're seeing in rheumatoid arthritis or psoriatic arthritis. You know, there's a cost of care, but the idea is we need to do better how we spend our money, how we develop new drugs, especially for osteoarthritis, which is still managed like it's in Neanderthal days using, you know, rocks, dust, prayer, oh, a little bit of nonsteroidals, we can do better. O N J. Have you seen it?

Are you worried about it? I know your dentists are. Osteoporosis of jaw, we know is a rare of bisphosphonate therapy. We reported a nice study comes, I think, of The UK, a half million people followed, over an average of eight years. They found a total of one hundred cases of osteonecrosis jaw who were admitted to the hospital.

That's the bias in this particular study. So, these numbers are probably worse than reality, but nonetheless are somewhat referable. And what they found was of those patients, a third were on bisphospherates, two thirds were not. They were all elderly. They were on bisphosphates or not.

Turns out the risk of having ONJ if you were not on a bisphosphonate was zero point zero nine per 1,000, or that's nine cases per 100,000 population in five years. If you were on a bisphosphate, it was zero point six nine per 1,000. That's seven cases per 10,000. These are still rare, rare numbers, but there's a magnitude of change here that's notable and worth paying attention to. Patients who had a prior history of cancer on their own were at higher risk for ONJ, the threefold higher risk.

Lastly, there's two more reports. One, long delays in the treatment of inflammatory arthritis, rheumatoid arthritis. In The UK, there's the Rheumatoid Arthritis Society. It's a nonprofit society that does audits based on standards of care established by NICE, N I C E, in The UK and Wales. They looked at the charts of over 20,000 individuals representing all the districts within The UK.

And the key findings of that study were that only four in ten patients with inflammatory arthritis, rheumatoid arthritis, met a three day standard for referral from their GP. Only forty percent were seen in a rheumatology unit within twenty eight days. And the average, I'm sorry, within three weeks. And the average wait time for an appointment was twenty eight days. These aren't bad, but these aren't great.

And as we talked about under the war in RA, we need to be great if we're really to change the outcomes in RA. We reported earlier in the year about antibiotics influencing the risk of developing rheumatoid arthritis, Yet we have another study, yet again from The UK. This time it's another UK primary care database, looked at eight thousand four hundred newly diagnosed RA patients and compared them to, in a case controlled manner, to twenty two thousand, not controls. So basically, what's that? It's about three to one, comparison RAs to controls, one to three, I should say.

If you are on antibiotics, you had a dose related increased risk of developing, rheumatoid arthritis with an odds ratio of two point six five. So, it's one hundred and sixty five percent increased risk if you had received greater than 10 antibiotics in the last five years. These numbers are not that dissimilar from that which we reported from another database in The UK, The UK Clinical Practice Research Database that looked at 22,000 patients compared them to a bunch of controls, and they showed an odds ratio increase of one point six or a sixty percent increase with antibiotic use, suggesting both studies suggesting both authors suggesting that this is a microbiome issue, and it could be other things, but it sort of does seem to indicate that the microbiome might be a major issue in the development of rheumatoid arthritis. You know, there's old data that actually says that recurrent, infections might lower the risk of rheumatoid arthritis. I don't know how that factors into this.

So, anyway, that's it. Make sure you go to the website, check out these citations and more. Make sure you come by the booth at ACR. RheumNow's got a booth. See these pens?

I'm evaluating pens for what our next giveaway is going to be. One of these might could be the one that you'll be carrying away from the meeting. I'm sure I can give you more than a pen at the ACR. We're gonna have great coverage. We've got a lot of faculty.

We're gonna put out lots of information, lots of videos. Should be a lot of fun. We'll see you in Atlanta in just a few weeks. Tune in next week.