RheumNow - RWCS 2018 - Day 1 Save

RheumNow is pleased to present the RWCS Daily podcast from the twenty eighteen meeting here in Maui. These podcasts are a compilation of each day's presentations by our featured faculty and presenters. We hope you enjoy these presentations from RWCS.

Thank you.

Hi. I'm Bevra Hahn from UCLA, and I'm speaking today at the RWCS meeting. And my topic is how to prevent atherosclerosis in patients with rheumatic diseases. So there are about three messages. The first is, there's good evidence that if we control disease activity in rheumatoid arthritis and in lupus, that we reduce cardiovascular events and therefore improve survival.

And the treatment in RA could be their data for TNF inhibitors, data for methotrexate, their data for hydroxychloroquine, all reducing mortality and cardiovascular events. In lupus, there are data for controlling disease, but they're not in very large numbers of patients. Now, then the second thing that we want to talk about is beyond controlling disease activity, are there other specific things we could do to lower risk? And the answer to that is also yes. There is good evidence that the addition of statin therapy in patients with rheumatoid arthritis reduces cardiovascular events and improves survival.

And there are recently good data in lupus that in patients who have hyperlipidemia, if you add a statin, that you reduce all case mortality significantly. So obviously that's very important. Now another important caveat in that study is that you have to give a standard dose of statin. If you give less than the recommended standard dose of statin, you don't get the benefit on death from, from all cause mortality. So we're waiting for those data to be confirmed by other studies.

They come from Taiwan, and they include fifty thousand lupus patients with hyperlipidemia. So in summary, when you're seeing patients, as you plan to reduce the disease activity, think also about things you might also do to reduce the chance for cardiovascular events, and that might include low dose aspirin in people with antiphospholipid or people who've had any kind of clotting event and introducing statins. And if you introduce statins, be sure to use, recommended standard doses and don't under dose if you want to have a good effect. Now, will you have patients with myopathy and other side effects of statins? They won't be any more common than in the general population on statins.

And, they aren't very common. But, in fact, you can work around them in most patients and have a good outcome in the very long term. Thank you.

This is Artie Cavanagh at RWCS two thousand eighteen talking about rheumatoid arthritis treatments and strategies and approaches. There was an interesting presentation this year about the IMPROVED study. The IMPROVED study was a treat to target study that looked at patients who did not go into remission after just methotrexate, randomized them to triple therapy with methotrexate sulfasalazine hydroxylchloroquine or to methotrexate plus TNF inhibitor. At the end, it was very successful. Many of the patients achieved remission.

Many of those, perhaps half of those who achieved remission, achieve drug free remission. They did a sub analysis which I think was very interesting to clinical practitioners, and that is that it was a treat to target strategy and patients were meant to accelerate therapy if they were not at remission. Patients patients who who did did accelerate accelerate did did better better than than those those who who did not accelerate and remain in low disease activity, but the differences were quite small and potentially not clinically meaningful. So I think this tells us what we do much in the clinic, and that is that we talk to patients, we involve them in the discussion, certainly as we're accelerating therapy, particularly if it involves adding a new medication or a significant change in that regard. So I think this tells us that maybe for some patients, low disease activity can be acceptable.

We always want to get patients to the lowest disease state we can, but we have to work with them to pick the optimal treatment approaches. This is Artie Kavanagh at RWCS twenty eighteen talking about rheumatoid arthritis treatments and treatment strategies. One of the things that we would love to have in rheumatology and certainly for the care of our patients with rheumatoid arthritis are biomarkers. There's an interesting study presented at the American College of Rheumatology meeting this past year in San Diego that looked at that, I think had some intriguing data. It was a sub analysis of the AMPLE study.

In the AMPLE study, rheumatoid arthritis patients on methotrexate who still had active disease were randomized to abetacept or adalimumab. Both treatment strategies proved very effective in improving the signs and symptoms of a disease, in making functional status better, and had benefits in terms of X-ray progression. This sub analysis took a number of factors, including the individual analytes that are incorporated into the MBDA or Vectra test, and using a number of other clinical and demographic and disease activity measures. What they were able to do, just by asking a computer program to sort out differences, was to find a pattern of a group of variables that actually predicted adalimumab response quite well and did not predict abatacep response very well, and vice versa. A different set of analytes could predict those patients who were going to have a very good response, meaning an ACR70 to abetacept, but this group of analytes was not predictive for adalimumab.

I think this is exciting, and I think it maybe points the way forward such that as we think of biomarkers in the future, we're not likely to find a single one that covers all patients and all treatments, and I think we may have to personalize them according to patient characteristics and to specific therapies, But by doing so, hopefully we'll get closer to finding the right drug for the right patient.

Hello. I'm Ann Stevens from Seattle Children's Hospital. I'm here at the RWCS meeting, and I just gave the pediatric rheumatology update. Today we talked about juvenile idiopathic arthritis classification. We have a classification system for JIA that is based on what we see in the clinic.

If you have five joints, you have poly JIA, less than five joints, you have oligo GIA and so forth. This system was established in 1999 and we've been using it ever since. New data over the last few years suggests that by looking at the biology of disease that we need to reclassify our patients into different categories and that the new categories are very compatible with the categories that we see in adult rheumatoid arthritis patients. And in fact, juvenile arthritis patients may not be so different from adult rheumatoid patients. For example, if you look at genetics, children older than six years old with rheumatoid factor positive disease are very similar genetically to adults with RF positive disease.

In contrast, children with RF negative disease are very similar to seronegative adult RA patients. We see these differences in the older kids, kids older than six. If we look at children less than six years old all bets are off. Children less than six years old are quite different genetically and biologically than adult patients and this is true for JIA, this is also true for lupus and for systemic sclerosis. Children diagnosed at an early age with these diseases have a higher genetic load, far more autoimmune associated genes and they have worse outcomes, more severe disease and need more chemotherapy and they have more morbidity and mortality.

So we're hoping that the next stage of JIA research will help us through looking at cellular phenotyping, gene expression phenotyping, and genetic phenotyping. It'll help us to classify patients so that we can use these biologic classifications to predict prognosis in children and to better predict who's going to respond to which treatment. The final point I made today was that a child being evaluated by a rheumatologist needs to be evaluated initially with the pediatric focus because the differential diagnosis in children is very different than the differential diagnosis in adults. For instance, children with swollen joints have more frequent rheumatic fever. They have a higher chance of having malignancy underlying their disease.

And the cases I presented today were four cases that we recently had in Seattle, Washington of children with swollen painful joints who actually have an underlying disease of scurvy or vitamin C deficiency. That's the pediatric update. Mahalo and Aloha.

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