The RheumNow Week in Review 10 August 2017 Save

It's the 08/11/2017 and this is the RoomNow we can review. My name is Jack Cush, I'm a rheumatologist and executive editor of roomnow.com and, we're going to review the highlights from the reports seen on RoomNow this week. A report from Finland looked at the incidence of rheumatoid arthritis in their population. One of the takeaways from this was that things that we know about RA and SPA and their prevalence seems to be evolving. Atul Diadar has been teaching us the last few years that, the incidence of SPA is probably greater than that of rheumatoid arthritis, and these numbers are borne out in this population based study.

They found that the incidence of rheumatoid arthritis was forty one per one hundred thousand. Incidence of spondyloarthritis, or a looser definition of spondyloarthropathy was close, thirty six per one hundred thousand, but probably excluded more rigid diagnosis including reactive arthritis which they found in eight per one hundred thousand. Where they're getting reactive arthritis, I don't know, even at that low number, I'm not seeing that in my practice, but they do see more of it in Scandinavia than we do here in North America. Equal to that scene of rheumatoid arthritis is the frequency of undifferentiated inflammatory arthritis with an incidence of three thousand nine hundred thousand. The latter part of the study actually looked at associations with PG and Givalis and antibodies of PG and Givalis and they found those to be correlated with men, ACMA positivity and no teeth or loss of teeth.

So, I guess the takeaway home, takeaway message from this is go to the dentist and, realize that, undifferentiated arthritis and spondyloarthritis may be as prevalent as rheumatoid arthritis in the population. Another interesting study looked at a literature review, to assess the issue of referral times and specifically looked at the lag time from the development of symptoms to, being referred, to being referred to the rheumatologist, and then ultimately getting on treatment. And the overall numbers that we're seeing here, the average from, I think 12 studies and 5,000 plus patients was was that the lag time from symptoms to receiving first DMARD was eleven point eight months or roughly a year. When you broke that down, the time from symptoms to seeing the first doctor was three months. These are average or, I'm sorry, median numbers.

From seeing the first doc and being referred to a rheumatologist was another two point one months, which I found actually a little surprising. From, seeing a rheumatologist and then having a firm diagnosis of inflammatory arthritis or rheumatoid arthritis was two point nine months. Is that the usual follow-up time or does it take them that long to make that diagnosis? And then again, the overall, time was, you know, almost twelve months. So again, I think there's been a trend towards improved referral times, but still there's a lot to, be changed here.

An interesting review looked at anti TIFF1 gamma antibodies. This is in a, I think, 155 kd, protein that has been associated with dermatomyositis or myositis associated cancer patients. And interestingly, in the studies that have been done, this antibody actually has been shown to have a 78% sensitivity and an 89% specificity. This particular study looked at whether or not anti TIF-one antibodies are seen in other rheumatic patients who have paraneoplastic syndrome or seen in just plain cancer patients, and the numbers that they found in their, cohort survey, review was something around one point three to three percent. So those these antibodies, again, they retain their sensitivity, specificity and they're seldom seen in, again, paraneoplastic rheumatic syndromes or patients just with cancer.

Found, going through my notes this week, I found a quote that I was supposed to have posted during the ACR meeting, actually during the ULAR meeting, and did not, and it comes from Peter Merkel wherein he was quoted to have said, Prednisone is the best drug we have. Prednisone is the worst drug we have. I like that. It got a lot of hits and retweets on social media because it resonates with us. I say prednisone is the greatest drug and the most hazardous drug that we use when I'm explaining it to patients.

I think this should be, this line from Merkel is definitely one that you may want to use and repeat. Another study comes from Joel Block and his group at Rush where they actually studied their frequency of problems in hepatitis C patients who received TNF inhibitors and they showed it was relatively infrequent that patients who went on etanercept had any problems if they had a background in hepatitis C. The caveat here is obviously that you will test patients for the LFTs and viral loads and follow them clinically while you give them a TNF inhibitor. Otherwise, the vast majority of patients can safely receive a TNF inhibitor. Tanezumab, a monoclonal antibody, against nerve growth factor, and there are several of them out there that are being developed, is now being fast tracked by the FDA as a non opioid pain reliever for use in osteoarthritis and probably other indications.

I think this is sorely needed because I don't know about you, but I have a hard time managing patients with OA of the hands, especially inflammatory OA, and my best therapy right now is very low dose prednisone, two point five milligrams along with acetaminophen that were the usual things we'd like to use in inflammatory OA, DMARDs or biologics really have no effect at all. A nice review of scleroderma and lung disease is seen, and posted on the site. One takeaway caveat here is that if you have interstitial lung disease associated with progressive systemic sclerosis, the five year mortality statistics are bleak, eighty two to ninety percent. Another tweet that went out that was sort of teaching bit from myself was you shouldn't text your patients, you shouldn't email your patients. Text medicine, email medicine is risky, it's incomplete, it's chancy, it may be convenient, but it's also usually not well documented in the usual medical record.

If you have a way of communicating with the patient through your EMR, that makes sense because you're documenting that but again, I wouldn't advise it. I think that, other than for simple questions and simple refills, do not practice email medicine or text medicine. It's too risky. An interesting study appeared this week in PLOS I about weather in arthritis. As you know, many of the studies about weather, have been able to make a clear correlation between joint symptomatology and changes in weather or changes in barometric pressure.

Two investigators got together and used Google and the Internet to assess the types of searches, and link that to temperature changes in certain, cities. They looked at 50 metropolitan area cities and they looked at a number of search terms and they correlated that with the barometric pressure and changes in weather and, actual temperatures, over a certain period. And what they found it was change in temperature that most closely correlated with hip and knee pain, and musculoskeletal pains in general. What did not correlate was rainfall or barometric pressure and it was only good up to a certain point. So I think it was up to 30 degrees centigrade that, went from minus five or five to 30 degrees centigrade is where you saw, as those temperatures rose, there was a decrease in hip and knee pain.

So, the exact opposite was seen with, rain, but there really wasn't a statistically significant change. Again, these changes were not noted for other pain, non musculoskeletal pains like abdominal pain, etcetera. So it may be that they well, at least the authors postulate that it is the change in temperature that allows people to do more or do less and that may be associated with more or less pain. An interesting report also appeared from a group of Saudi Arabian physicians who studied a cohort of patients who presented to primary care, and they looked at issues or the factors which made for the most productive referrals. So in this study, they trained their doctors, within a few days, with two days of training on how to do an assessment and joint exam.

And they included patients in the study who were, over 18 and who had referrals, who had presented with hand pain. And the factors that they saw that had predictive value, in yielding those patients proven to have inflammatory arthritis by the rheumatologist examination and assessment were the following: loss of appetite, swelling of the MCP II or V, swelling of PIP II or III, wrist swelling and wrist tenderness, a positive rheumatoid factor or a positive CCP antibody. They set their threshold for, being a good criterion were those that actually had, a positive predictive value of greater than seventy five percent, a high likelihood ratio greater than two, a specificity of about ninety percent or higher. So these seem to be reasonable. Loss of appetite, I'm not sure why that is.

It may be a reflection of inflammation. Swelling of MCPs and PIPs in the wrist makes sense, and as does the serology. So remember, the Paul Emry criteria for early referral of inflammatory arthritis included three or more swollen joints, a positive MCP squeeze test like this, an MTP squeeze test would also suffice, and then morning stiffness of greater than thirty minutes. I think these are somewhat similar. What's interesting is that we don't yet have these criteria being put to the test with a real performance, rating, if you will.

And I think that we need more tests like this, more studies like this. We need more importantly, ability to take good information and bring it to the primary care sector as hard and fast rules that should govern whether or not patients should be referred. And then lastly, you may have seen at the beginning of the week that musculoskeletal ultrasound is now included in nearly every US rheumatology fellowship training program. While I remarked that ten years ago when we would do, programs with fellows, it seemed like a little more than half of the fellows were either being trained in ultrasound or had access to ultrasound. Now the number is about ninety one percent.

So the investigators here, surveyed all of the 113 program directors, had over a 90% response rate, found that 94% of programs do have teaching in ultrasound, and that forty one percent of the programs actually have a formal curriculum that the fellows must go through. So this has become a major part of rheumatology. The question is, will the younger rheumatologists be better at the job than we are? Will they be able to use this tool to some, better goal or better outcome? It's not necessarily clear that treating to an ultrasound remission yields better outcomes than usual clinical metrics.

But it is interesting to note that these are being used more frequently. In my own practice, we have an ultrasound machine. I seldom use it. I have a younger colleague, Rachel Tate, who's fabulous at it. I'm seeing her carton that thing around all day long and she's getting a lot of use out of it and I'm sure she's doing a great job.

The question is, is it time efficient? Is it cost efficient? Is it reasonable to get reimbursed on? Again, there's a new era of rheumatology ahead and ultrasound's a part of it. That's it for this week.

Go to RheumNow to see these links and to read more about these articles. Be sure to look at our new therapeutic, update, a new feature on RheumNow that you'll see in the daily email, also on the website where we'll discuss new issues in therapeutics. This week, we have a video up about, the proceedings of the FDA hearing on cirucoumab. Next week, we'll be proceedings on the FDA hearing regarding tofacitinib and its approval or potential approval for psoriatic arthritis. That's it.

Tune in soon. Bye.