The RheumNow Week In Review - 10 November 2017 Save

Hi. I'm Jack Cush, executive editor of roomnow.com. It is the 11/10/2017, and this is the RheumNow we can review. Actually, it's a whole lot more than the weekend review. It's the ACR two thousand seventeen meeting in review.

We just got back from San Diego. The meeting started on Sunday, ended on Wednesday. It was jam packed. It was really quite a good meeting held in San Diego, a great host town. We posted from RheumNow, we posted almost 900 pieces of news items on our website and on our microsite for people to follow along and see what we did.

My congratulations to the 13 individuals who served as RheumNow faculty who did really a fabulous job in covering the meeting. So in trying to review the meeting, that would be impossible. You really should go to the website and take a look at that. It's a cr17.rheumnow.com. You can view it by day.

You can view it by topic. You can view it by gout or ankylosing spondylitis or psoriatic arthritis, whatever, you know, floats your boat. It's all there. A lot of tweets which are basically single statements from a session that was a teachable moment. There were a number of good articles written along the meeting that summarized some of the sessions.

There were great videos done by 70 your 70 videos or more of your best friends and faculty and KOLs talking about their work. So I'll cover a few things today. At the top of the news, I think I wanna cover a plenary session that was done by Doctor. Greg Silverman of NYU in New York, where he had a really novel presentation on the microbiome and lupus. Check out the video that we have that you can find on the website that where he sort of summarizes the whole event.

But basically what he did was he studied lupus patients and then looked at their microbiome and had to recruit enough patients to do this. And they genetically analyzed the species that were involved in the microbiome. They basically found that if your lupus was inactive with a sleek eye score of two or less, you pretty much had a normal microbiome compared to normal controls. However, that when they looked at increasing levels of activity, they found an expansion of a single species that was called Rheumatococcus novice that was unique and that more importantly, were able to show that as your disease activity level went up, so did the levels of the species, and so did its association or correlation with double stranded DNA production and the risk of lupus nephritis. So this is a very novel finding, maybe one of the first actually showed that a microbiome change is clinically correlated with the outcomes.

And this may be a whole new line of therapy and investigation in lupus. Congratulations to Greg and the and the team at NYU. Secondly, I wanna point out that if you go to the the website or the microsite, you can actually pick up podcasts from each day, day one, two, three, and four. We took the video cast from all of our faculty and all of our friends and key opinion leaders and research presenters that we got to do videos with, and we strung them together in one hour videos for each one hour podcast for each day. I think you'll find those useful, especially if you do long drives or you run and like to listen to something.

You can download those from Soundhound or you or from iTunes, and you can follow those and get a taste of the meeting at least from the RheumNow perspective. My third news bit comes from my own center, and this is a senior resident at the Baylor University Medical Center, Darrell Scott and White University Medical Center in Dallas, with Doctor. Brooke Mills, who's been working with Catherine Dow and Rachel Tate and myself in developing the plan registry. This is a pregnancy and lactation registry, and kudos to them. This is abstract three fifty five, where they basically were able to enroll over 150 patients and survey them about, their plans for pregnancy, their impressions of pregnancy and lactation.

And interestingly, they showed in their report that over a third of patients changed their plans regarding lactation, and over a half of them changed their view of pregnancy once they got their diagnosis. So the point of the registry is really to assess women, by surveys as far as their impressions and perceptions and how the disease colors all of that. What they really found at its core was that the diagnosis, the disease, the drugs we use significantly impact the patients and their thinking about their future, about their pregnancy future, whether or not they plan to breastfeed in the future, and maybe even how they will take therapy. So this is the beginning of a prospective registry. I think it's an important advance from the perspective of looking at women and their impressions plans for the future, especially what happens after they deliver the baby.

So this will be very valuable information in the future. Next, Jeff Curtis had a really good plenary session on bisphosphonate holidays. And in his report, he looked at a large number of of people who, were being followed for in claims data, and specifically looked at those who had not been on a bisphosphonate, started bisphosphonate, and alendronate sort of led the way with the bisphosphonate and then saw what happened when they stopped their bisphosphonate. So on average, this very large cohort had been off of a bisphosphonate for almost three years. I think they had to be on a bisphosphonate, and then we looked at their index point of being of stopping of bisphosphonate.

And what he saw was that there was a clear cut increased risk of fractures, especially hip fractures, as time went on. The point being that a drug holiday, you know, shouldn't be forever, that the longer you went on when there was the numbers got increasingly greater as far as fracture risk. And once it got up to two years and above, that's when the fracture risk started to take off. And again, it was about forty percent increase in hip fractures after two years. So I think it's important because I'll have to go back and tell my patients, maybe you don't want to be off this bisphosphonate too long.

That we'll go off for a year, but especially I think the rule is if the patient has osteoporosis and is at high risk for fracture, going on a drug holiday makes no sense at all. The benefits of the bisphosphonates far outweigh the risk. If they're in the osteopenic and low number range, there may be a good rationale to a drug holiday and this data tells me that I might wanna do it for a year but not beyond two years. Another great plenary session came from Park et al and we have a video by that. I think Cassie Calabrese had a great video explaining what happened.

And they specifically looked at RA patients who were gonna get influenza vaccination and they had a pilot study to look at different time periods where you might wanna stop the methotrexate. Based on that data, and they wanted to see the data that had the best immune responses to the vaccine and the least amount of flare of rheumatoid arthritis, they decided that they would stop methotrexate at the point of influenza vaccination and be off of methotrexate for two weeks and then go forward. And in fact, they were able to show that they met all their their benchmarks of, you know, a fourfold immunization and titer, seroconversion, low risk of actually developing influenza, and very low chance of developing a flare of their rheumatoid arthritis. So I think this was an important report because it will go back and change your practice. What I'm gonna do based on this is I see an RA patient who needs to be vaccinated.

We'll vaccinate them against influenza and tell them to hold their methotrexate for two weeks, but then resume it thereafter. Again, it doesn't matter if they're on biologics or not. This is an inactive virus, so it can be given at any time, and methotrexate is the only drug you can you you should manipulate. There was no other advice, about what to do with prednisone or other DMARDs that wasn't studied here, so I can't advise you here. They had many people on steroids and steroids, and methotrexate.

But, again, you're you can keep all those other medicines going. But with regard to methotrexate, hold it two weeks and then proceed. Another great presentation was a late breaker from Philip Mies where he described the results of secukinumab in psoriatic arthritis patients. This is called the future five study. And I I here they looked at basically X-ray outcomes showing that whether you had three hundred milligrams or one hundred fifty milligrams or placebo, that those patients that were on secukinumab had radiographic protection over time that was impressive, and that and they also looked at a group that didn't have a loading dose.

So it seemed like, again, all the outcomes are about the same for all the groups. The only thing here was that for me to take home was that and you should look at the video and see what Philip has to say about it, but the patients who didn't have a loading dose actually did very well provided that they were not a TNF inhibitor failure. If they had not previously failed the TNF inhibitor, getting a loaded dose loading dose didn't wasn't as important. But if they were previously a TNF inhibitor failure, you probably should use the IV loading dose and then go on with your usual regimen to obtain optimal efficacy responses and safety outcomes, but also X-ray outcomes. So, again, I think that's really for the efficacy point, you should divide patients up into whether or not they were are naive or not to a TNF inhibitor.

Upon recession abstract number seventeen eighty eight looked at the osteoarthritis initiative and identified patients who had intra articular steroid injections. And basically, they showed that if you did, that you are at much greater risk of developing knee progression and the need for knee replacement. Much of the fivefold increased risk if you were getting an intra articular knee injection. So now again, does that mean we shouldn't use it? Again, there was a lot of debate at the meeting about whether this is truly important or whether this is confounded by indication that obviously people with pain and worse disease are gonna get more and hence they're gonna be later patients who will progress and may need replacement.

But I think it does tell us that there could be a downside to injection. There are recent reports in the literature certainly saying that if patients do need future knee replacement, that they should not have an intra articular steroid injection within six months of planned replacement because the complication rates, the infection rates are much higher. This data about injection and progression suggests that, again, it might be a marker for patients who will progress and that you shouldn't be doing this unless there's an intended benefit and not necessarily a plan for replacement. So again, somewhat debatable, look at the data yourself and look at what we have online. I think you'll be interested in this data.

And I found a number of our friends, in fact, who did videos, Al Jaboski did a video on a paper that I didn't know about where he talked about prednisone use and steroid use in general as a financial marker for the cost of care in rheumatoid arthritis. Dividing patients up into those who are on no and less than seven, and this was low, medium, and high prednisone use divided by increments of seven point five milligrams, he was able to or saw that there was a significant increase in the total cost of care in those patients. So it's not surprising that prednisone would therefore be a surrogate marker for patients with the worst disease, and that in itself is instructive, but it's a nice snapshot of your patients who you are taking care of to you know, a lot of patients are on five, but once you start getting above five, you should be thinking about how well am I doing here and if prednisone is really part of the solution or part of the problem. So again, it does show clear correlation between the amount of prednisone being used at a daily dose and the overall cost of care.

They didn't express that in outcomes like death and surgery, but you can assume that they'll go up as things get worse. A novel thing that I learned at this meeting was the potential involvement of a JAK inhibitor, baricitinib, in improving pain. Certainly, you would expect that all drugs that work improve pain, whether it be any biologic TNF inhibitor, DMR, it doesn't really matter. They all improve pain as part of the outcome measures. But in this particular study, which was actually reported by Peter Taylor, was a sub analysis of one of their studies where they had a head to head between baricitinib and patients on adalimumab and placebo.

And they showed that baricitinib patients, the JAK inhibitor, had a far greater and faster reduction in pain scores than did the patients who were on the TNF inhibitor or placebo. So again, does that say something unique about baricitinib or JAK inhibitors? Again, this is early research. I think the company is going to look at this further, but it's an interesting question to look at going forward. Could there be a differential response in pain responses on a JAK inhibitor or specifically baricitinib?

It remains to be seen. We do know and it's very hard to quantitate what happens with the TNF inhibitors. I've written about on RheumNow that TNF inhibitors are associated with the born again rheumatoid thing. That you give someone a TNF inhibitor, they feel fantastic right away even before their joints are better and they wanna go bungee jumping and join the Marines. That's the born again thing.

It's almost like it's a CNS effect more so than a joint specific effect. I don't think that this is what they're talking about with baricitinib and JAK inhibition. I think they're specifically talking about pain. So this needs to be looked for in the future. We had a nice video on our site from doctor Olga Petrina who reviewed the results of a session where, authorities at Memphis Hospital in New York have developed an algorithmic approach to patients with scleroderma specifically to look at pulmonary hypertension.

And on their algorithmic approach, wanna look at patients who have early disease, of course, but really screening should begin in those with three years or more of disease, and they look at things like the ratio of FVC to DLCO, presence of telangiectasias, BNP, uric acid, EKG showing the right axis deviation, being indicators in the algorithm for one for whether one needs to be screened further with an echo first and then ultimately lady later maybe right heart catheterization. So I think it's an important advance because I see these patients and my decisions about pulmonary hypertension as a risk are more driven by symptoms and worry that come on late rather than being proactive in identifying this problem early on, which is the point of the presentation, having an approach that identifies patients early. So congratulations to Olga Petrina for finding that. My last report, think, is just a synopsis of the opening lecture, the keynote speaker, Doctor. Anthony Fauci, the head of the infectious disease division at the NIH.

Tony has been around for a long time. He's the editor of Harrison's textbook of internal medicine. He's on Nightline. He's the go to guy on infectious issues in The United States. His presentation was another masterful presentation from a man who knows how to educate and get the message across.

And he spoke really about his career serving under five presidents beginning with Ronald Reagan, next with George Bush senior, then Bill Clinton, then George Bush junior, and then, lastly, Barack Obama. And and really going through the infectious complications that he has witnessed and managed over five different presidents and a career in medicine. And he during this time, he covered HIV, SARS, swine flu, Ebola, and lastly, the Zika virus as things to worry about and how he dealt with those. Really a novel presentation, one that could only be done by the master like Tony Fauci. And in the end, his take home was that we need to have plans for global surveillance.

We need to have transparency and communication between our government, the White House, and our researchers. There needs to be an infrastructure and capacity to develop programs as need be based on need. What he basically said is every presidency, and this was advice to the new Trump presidency, every presidency is going to deal with a pandemic and an epidemic in our country that will affect the populace and that they're at the forefront in dealing with this. They also need to have a platform for developing new technologies, especially vaccines. He showed that the development of vaccines went from over twenty four months, I think, twenty months in the beginning down to three point five months with development of a Zika virus vaccine, and that there needs to be a public health emergency fund for funding of a lot of these individual problems.

So congratulations to Doctor. Fauci for again another masterful presentation that benefits his friends in rheumatology. He said he was once a rheumatologist. I still think he is. Lastly, I want to congratulate the ACR and its staff for all their hard work at a great annual meeting.

It really was a success. We should also thank our outgoing President, Sharad Lachenpahl, who really kept his finger on the pulse of developments in the government issuing a lot of new policy statements that were beneficial in having a voice at national level and with the new administration. Congratulations to Doctor. David Dyke for becoming the new incoming president of the ACR. We wish him a lot of luck and we certainly look forward to his leadership and guidance for all the things that affect us as rheumatologists in 2018.

Tune into RheumNow, go to the website to get these links and more. Go to acr17.roomnow.com if you wanna see what happened at the last meeting. Thanks so much.