The RheumNow Week In Review 14 April 2017 Save
The RheumNow Week In Review 14 April 2017 by Dr. Cush
Transcription
Hey now. It's the 04/14/2017. This is the RheumNow we can review, and I'm doctor Jack Cush. This week, I'm coming to you from Dallas, Texas with all the good news from the website, rheumnow.com. The Nurses Health Study, a study of 8,947,000 nurses studied for the last ninety five years has given us lots of studies.
Lots of results about population related phenomenon, the effects of certain lifestyles on disease outcomes. A recent report, I think an important report from the Nurses' Health Study looked at the influence of diet. And specifically, they looked at women who identified themselves as eating a healthy diet and what that might have done as far as the risk of developing rheumatoid arthritis over time. With a fairly large cohort size and, a good definition of diet, they showed that there was a trend towards a reduction in the risk of rheumatoid arthritis that only became significant when they adjusted for smoking and obesity. Again, now three factors that seem to be important in disease pathogenesis for many states, but especially for rheumatoid arthritis.
So, clearly smoking, clearly obesity have been well known risk factors, and now the Nurses Health Study shows us that, a good diet, one that's rich in vegetables and fruits and fish and whatnot, is actually quite good at preventing the onset of rheumatoid arthritis. Important for those people who may be at risk, for rheumatoid arthritis being a first degree relative and whatnot. An interesting study, from Germany, Jurgen Braun's group, looked at what they thought was a fairly common practice, I was unaware of, and that is the use of a short pulse of steroids to distinguish between new onset RA and osteoarthritis. In their clinic, had ninety five patients who were prospectively studied. They were newly presenting.
It wasn't quite clear what their diagnosis was, and when followed out, it was shown that those who received a twenty milligram a day dose for three days was more likely to be effective in patients with rheumatoid arthritis compared to those with osteoarthritis. Again, not a great sensitivity to this test. Fifty percent responses in those who had rheumatoid, only twenty percent in those who had osteoarthritis. The predictive values, were reasonable suggesting this could be used in practice. The positive predictive value was point seven seven, the negative predictive value was 0.7 or seventy percent.
A follow-up study from the Swedish registry looked again at lymphoma. We know the Baikalin group has been famous for their data about the risk of lymphoma and cancer in patients with rheumatoid arthritis. This is the same group that showed us that like other groups that rheumatoid arthritis patients are at higher risk for lymphoma specifically, and that the risk of lymphoma is directly tied to disease activity, seventy plus fold, higher risk for lymphoma if you have the highest rates of disease activity. Well, they did a follow-up with their cohort, very large cohort who have been followed on multiple drugs, including DMARDs and biologics. And they showed again that lymphoma is higher in RA patients at a rate that's about what that has been seen in other historic controls including their own.
But what they also showed, again, and reconfirmed for maybe the tenth time now, is that the use of DMARDs and TNF inhibitors did not increase the risk of lymphoma above that realized by RA alone. An important point for those patients who you have to treat where lymphoma is the issue. A study on rheumatoid arthritis, patients looked at what the influence of BMI and obesity was on acute phase reactants. It's quite instructive. I don't know about you, but I I I sometimes see patients with elevated ESRs and CRPs, and they don't have any evidence, or risk factors for why that would be so.
They don't have inflammatory disease, and you go undergo a long search for this. Well, they did show in this particular population based study that higher BMIs were certainly associated with higher CRP levels, and this was especially true in women, especially in true women who had morbid obesity and obesity. A lesser effect was seen with sed rate also in women who were obese. And men, while they did have some effect of, obesity on acute phase reactants, it wasn't the same as that as observed in women. So, somewhat instructive for those who look to interpret such results.
A nice study looked at the effects of, activity on fatigue in patients with rheumatoid arthritis. In this particular study, they actually took patients, and gave them either instruction or they gave them a pedometer and gave them goals. And it turned out that, with step goals and with a pedometer that obviously patients, moved more, had more exercise, and those patients had a significant reduction in their fatigue levels compared to those who did not, who just had basic education. And that recent analysis looked at whether safety data seen in rheumatoid arthritis patients and psoriatic arthritis patients are comparable, and in fact, they are not. What they actually showed in this study was that death rates and serious adverse events were forty less, forty percent less in the psoriasis populations compared to the rheumatoid arthritis patients.
Rheumatoid arthritis patients had two a twofold higher rate of SAEs, serious adverse events, including more cardiac events and more infectious events. So, again, while a lot of the safety signals are the same between these two, they're not quite as magnified in the psoriatic population. A very large study, 53,477 new TNF inhibitor, starts showed that up to thirty seven percent or a third were actually, I'm sorry, adherence was only thirty seven percent. That means two thirds were non adherent and then but eighty three percent were persistent, meaning they stayed on the drug for the most of the year. Adherence and persistence was actually lowest in young adults, those with multiple comorbidities, those who had had hospitalizations and frequent ER visits.
Again, this is a big problem for a lot of our patients, especially with drugs that are expensive. A nice report in today's, edition of the RheumNow looked at steroid use. I've always said the steroids are acutely wonderful chronically hazardous, meaning that the risks are much greater with prolonged use and higher dose use. But this particular study, looked at a number of different sources and showed that within, actually I looked at, it was a claims data, and it was over one point five million lives, and they looked at those who took steroids versus those who did not. And overall, they found that one in five patients were given a short course of steroids, in a three year period.
To me, that's sort of an astounding number, meaning that steroids are being thrown around like candy to fix a lot of different ailments. This would be for allergies and asthma and rashes and arthritis, etcetera. What they did show is that those who did take steroids had a significantly higher rate of certain adverse events and that were particularly high within, the first thirty days after the use of the drug. So, what they showed was, that sepsis was fivefold higher, that venous thromboembolic events were threefold higher, and that fractures were 1.87 fold higher or an eighty seven percent increase. So, steroid use is not benign.
Acute steroid use may come with an increased risk of those three particular adverse events. Thankfully, those events are rare in the general population, and when being five or three or two fold higher, it may not seem like much of a risk, but in fact it is higher and that acute steroids are not totally benign. Selicoxib was studied recently. You know, there's lot of data about Selicoxib, the precision study showing its GI and cardio protective effects. The concern study was a study done in Taiwan, a single a single center study of 514 patients seen over a three year period, and patients were given either, naproxen or celecoxib with a background PPI.
Now, the interesting thing is that these are pretty high risk patients. These are patients with arthritis, seventy plus percent had osteoarthritis, and had a cardiovascular history, and they had a recent GI bleed. And they then went on to treat them with a non steroidal, I'm not sure why that would have been done, and thankfully the celecoxib dose was only a hundred milligrams bid. But nonetheless, they what they did show that between the options given, and a lot of these patients were on background aspirin, that there was a significant reduction in gastrointestinal bleeds if you're using celecoxib compared to naproxen with both groups getting a PPI. In fact, there was a 44% significant reduction in the celecoxib group.
They also looked at cardiovascular outcomes, and while there was a twenty two percent lower rate in the celecoxib group of cardiovascular outcomes, ATPC adjudicated events, that was not significant, just a trend. So if you have to use, a nonsteroidal, obviously, a celecoxib and PPI might be the right one to use if you're using low doses. Now, again, this is done in Taiwan. They might be able get away with lower doses than what we may be using in The United States, but it is still nonetheless instructive. A recent JAMA article looked at the utility of spinal manipulation.
This is a follow-up to a number of different studies that looked at acute low back pain in the intervention scene. The headline we used was that spinal manipulation was about equal to nonsteroidals. Previous headline on the same subject said that nonsteroidals were not all that effective. In fact, were modestly effective. And that's all that was seen here, that there was a modest effect in those patients with acute low back pain.
A systematic review of osteoporosis drugs that were given to those who had chronic kidney disease, showed a fairly uncertain effect. Now, we know that the effects of bisphosphonate, teriparatide teriparatide even, are certain with regard to their improvements in BMD and reductions in fracture rates. However, the same cannot be said when these drugs are applied to a high risk population for osteoporosis, that being those who have CKD. So, variable effects on fracture rates, variable effects on BMD, more research is needed in this area. Something I wasn't quite aware of, but lupus patients we do know can have stroke as an outcome.
They can be ischemic, they can be hemorrhagic. Turns out that the risk of of stroke or ischemic or hemorrhagic is highest in lupus patients within the first year of diagnosis. That's based on a fairly large population based study in Sweden. Again, the rate that was seen in this population was twofold higher than the general population, and that in the first year was three point sevenfold higher for lupus patients. So, first year you might be on the lookout, you might want to, more aggressively evaluate your patients for stroke risk factors if they have a new diagnosis of lupus.
That's it for roomnow.com. Go to the website to get the links. Be sure to go to the website and register. That would be doing me a great favor. Tune in next week where we'll give you more news from rheumnow.com.
Goodbye.
Lots of results about population related phenomenon, the effects of certain lifestyles on disease outcomes. A recent report, I think an important report from the Nurses' Health Study looked at the influence of diet. And specifically, they looked at women who identified themselves as eating a healthy diet and what that might have done as far as the risk of developing rheumatoid arthritis over time. With a fairly large cohort size and, a good definition of diet, they showed that there was a trend towards a reduction in the risk of rheumatoid arthritis that only became significant when they adjusted for smoking and obesity. Again, now three factors that seem to be important in disease pathogenesis for many states, but especially for rheumatoid arthritis.
So, clearly smoking, clearly obesity have been well known risk factors, and now the Nurses Health Study shows us that, a good diet, one that's rich in vegetables and fruits and fish and whatnot, is actually quite good at preventing the onset of rheumatoid arthritis. Important for those people who may be at risk, for rheumatoid arthritis being a first degree relative and whatnot. An interesting study, from Germany, Jurgen Braun's group, looked at what they thought was a fairly common practice, I was unaware of, and that is the use of a short pulse of steroids to distinguish between new onset RA and osteoarthritis. In their clinic, had ninety five patients who were prospectively studied. They were newly presenting.
It wasn't quite clear what their diagnosis was, and when followed out, it was shown that those who received a twenty milligram a day dose for three days was more likely to be effective in patients with rheumatoid arthritis compared to those with osteoarthritis. Again, not a great sensitivity to this test. Fifty percent responses in those who had rheumatoid, only twenty percent in those who had osteoarthritis. The predictive values, were reasonable suggesting this could be used in practice. The positive predictive value was point seven seven, the negative predictive value was 0.7 or seventy percent.
A follow-up study from the Swedish registry looked again at lymphoma. We know the Baikalin group has been famous for their data about the risk of lymphoma and cancer in patients with rheumatoid arthritis. This is the same group that showed us that like other groups that rheumatoid arthritis patients are at higher risk for lymphoma specifically, and that the risk of lymphoma is directly tied to disease activity, seventy plus fold, higher risk for lymphoma if you have the highest rates of disease activity. Well, they did a follow-up with their cohort, very large cohort who have been followed on multiple drugs, including DMARDs and biologics. And they showed again that lymphoma is higher in RA patients at a rate that's about what that has been seen in other historic controls including their own.
But what they also showed, again, and reconfirmed for maybe the tenth time now, is that the use of DMARDs and TNF inhibitors did not increase the risk of lymphoma above that realized by RA alone. An important point for those patients who you have to treat where lymphoma is the issue. A study on rheumatoid arthritis, patients looked at what the influence of BMI and obesity was on acute phase reactants. It's quite instructive. I don't know about you, but I I I sometimes see patients with elevated ESRs and CRPs, and they don't have any evidence, or risk factors for why that would be so.
They don't have inflammatory disease, and you go undergo a long search for this. Well, they did show in this particular population based study that higher BMIs were certainly associated with higher CRP levels, and this was especially true in women, especially in true women who had morbid obesity and obesity. A lesser effect was seen with sed rate also in women who were obese. And men, while they did have some effect of, obesity on acute phase reactants, it wasn't the same as that as observed in women. So, somewhat instructive for those who look to interpret such results.
A nice study looked at the effects of, activity on fatigue in patients with rheumatoid arthritis. In this particular study, they actually took patients, and gave them either instruction or they gave them a pedometer and gave them goals. And it turned out that, with step goals and with a pedometer that obviously patients, moved more, had more exercise, and those patients had a significant reduction in their fatigue levels compared to those who did not, who just had basic education. And that recent analysis looked at whether safety data seen in rheumatoid arthritis patients and psoriatic arthritis patients are comparable, and in fact, they are not. What they actually showed in this study was that death rates and serious adverse events were forty less, forty percent less in the psoriasis populations compared to the rheumatoid arthritis patients.
Rheumatoid arthritis patients had two a twofold higher rate of SAEs, serious adverse events, including more cardiac events and more infectious events. So, again, while a lot of the safety signals are the same between these two, they're not quite as magnified in the psoriatic population. A very large study, 53,477 new TNF inhibitor, starts showed that up to thirty seven percent or a third were actually, I'm sorry, adherence was only thirty seven percent. That means two thirds were non adherent and then but eighty three percent were persistent, meaning they stayed on the drug for the most of the year. Adherence and persistence was actually lowest in young adults, those with multiple comorbidities, those who had had hospitalizations and frequent ER visits.
Again, this is a big problem for a lot of our patients, especially with drugs that are expensive. A nice report in today's, edition of the RheumNow looked at steroid use. I've always said the steroids are acutely wonderful chronically hazardous, meaning that the risks are much greater with prolonged use and higher dose use. But this particular study, looked at a number of different sources and showed that within, actually I looked at, it was a claims data, and it was over one point five million lives, and they looked at those who took steroids versus those who did not. And overall, they found that one in five patients were given a short course of steroids, in a three year period.
To me, that's sort of an astounding number, meaning that steroids are being thrown around like candy to fix a lot of different ailments. This would be for allergies and asthma and rashes and arthritis, etcetera. What they did show is that those who did take steroids had a significantly higher rate of certain adverse events and that were particularly high within, the first thirty days after the use of the drug. So, what they showed was, that sepsis was fivefold higher, that venous thromboembolic events were threefold higher, and that fractures were 1.87 fold higher or an eighty seven percent increase. So, steroid use is not benign.
Acute steroid use may come with an increased risk of those three particular adverse events. Thankfully, those events are rare in the general population, and when being five or three or two fold higher, it may not seem like much of a risk, but in fact it is higher and that acute steroids are not totally benign. Selicoxib was studied recently. You know, there's lot of data about Selicoxib, the precision study showing its GI and cardio protective effects. The concern study was a study done in Taiwan, a single a single center study of 514 patients seen over a three year period, and patients were given either, naproxen or celecoxib with a background PPI.
Now, the interesting thing is that these are pretty high risk patients. These are patients with arthritis, seventy plus percent had osteoarthritis, and had a cardiovascular history, and they had a recent GI bleed. And they then went on to treat them with a non steroidal, I'm not sure why that would have been done, and thankfully the celecoxib dose was only a hundred milligrams bid. But nonetheless, they what they did show that between the options given, and a lot of these patients were on background aspirin, that there was a significant reduction in gastrointestinal bleeds if you're using celecoxib compared to naproxen with both groups getting a PPI. In fact, there was a 44% significant reduction in the celecoxib group.
They also looked at cardiovascular outcomes, and while there was a twenty two percent lower rate in the celecoxib group of cardiovascular outcomes, ATPC adjudicated events, that was not significant, just a trend. So if you have to use, a nonsteroidal, obviously, a celecoxib and PPI might be the right one to use if you're using low doses. Now, again, this is done in Taiwan. They might be able get away with lower doses than what we may be using in The United States, but it is still nonetheless instructive. A recent JAMA article looked at the utility of spinal manipulation.
This is a follow-up to a number of different studies that looked at acute low back pain in the intervention scene. The headline we used was that spinal manipulation was about equal to nonsteroidals. Previous headline on the same subject said that nonsteroidals were not all that effective. In fact, were modestly effective. And that's all that was seen here, that there was a modest effect in those patients with acute low back pain.
A systematic review of osteoporosis drugs that were given to those who had chronic kidney disease, showed a fairly uncertain effect. Now, we know that the effects of bisphosphonate, teriparatide teriparatide even, are certain with regard to their improvements in BMD and reductions in fracture rates. However, the same cannot be said when these drugs are applied to a high risk population for osteoporosis, that being those who have CKD. So, variable effects on fracture rates, variable effects on BMD, more research is needed in this area. Something I wasn't quite aware of, but lupus patients we do know can have stroke as an outcome.
They can be ischemic, they can be hemorrhagic. Turns out that the risk of of stroke or ischemic or hemorrhagic is highest in lupus patients within the first year of diagnosis. That's based on a fairly large population based study in Sweden. Again, the rate that was seen in this population was twofold higher than the general population, and that in the first year was three point sevenfold higher for lupus patients. So, first year you might be on the lookout, you might want to, more aggressively evaluate your patients for stroke risk factors if they have a new diagnosis of lupus.
That's it for roomnow.com. Go to the website to get the links. Be sure to go to the website and register. That would be doing me a great favor. Tune in next week where we'll give you more news from rheumnow.com.
Goodbye.
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