The RheumNow Week In Review - 19 January 2018 Save

Hello. It's the 01/19/2018. This is the RoomNow we can review. I'm doctor Jack Cush, executive editor of roomnow.com. This week in the news, rheumatology burnout, what?

Next thing you'll know they'll be retiring. And what about rheumatoid arthritis and weight loss? Is there really a link? And how do you get there? And lastly, could rheumatoid arthritis be associated with hearing loss?

And could that be the reason why patients may not follow your instructions? All this and more. At the top of the news, a follow-up to what we reported last week about checkpoint inhibitors and their potential autoimmune side effects. As you may remember, last week there was a nice review, both by, Len Calabrese and others, and then a nice meta analysis of the side effects you get with checkpoint inhibitors and what happens when they're given to people who have autoimmune disease. And so that was a nice sort of refresher and a new angle on this.

This week we follow we follow-up with another report that looks a lot like the report from Maria Suarez Almezar where she did an analysis of the literature to look at what happens when checkpoint inhibitors are given to patients who have autoimmune disease, and she found as much as a seventy five percent flare rate in those people. The report that we have this week on our website says that it's a little bit lower, but it still is fairly high. Forty four percent of the patients who had autoimmune inflammatory diseases had, the manifestation either of a new autoimmune inflammatory disease or exacerbation flare of preexisting disease. So it appears that our patients may be more poised to what happens when you start inhibiting CTLA-four or PD-one or PD L1 and there needs to be some lessons learned from that and certainly a higher index of suspicion in managing such patients. So again, is sort of supported data, supported data of what we saw in the previous week's reports.

A New York Times article, this week reviewed some of the, issues surrounding cost of drugs and they they went right after adalimumab or Humira being that number one, it's the world's largest selling of all biologics. In 2017 selling the projections were about, I think, $18,800,000,000 worth of drug worldwide. And that they have steadily every year increased the price of the drug by as much as 6%. So they actually did a review and pointed out that, or they noted a review that was published, in 2016 that looked at 2015 prices and showed that the price of two syringes of Humira was $2,670 in The United States. It was half that in The UK, 1362, about the same, maybe a little bit less in Spain.

But in Switzerland, it was only $822 and in South Africa, it was only $552. Hence, we're paying five times as much as South Africa. We're paying four, three plus times as much as Switzerland and twice that as seen in many of the European nations. Why the discrepancy? Why this can't all be the same?

I think it's a big mystery to all of us. I think that, you know, that whatever the market will bear and that's obviously an issue for the payers here in The United States. But those are real life numbers for what's going on, and you may have to send your patients to South Africa if they need a financial break. My partner, Doctor. Catherine Dow, found a nice article from the Wall Street Journal where she says that cursing, and using swear words is a nice way of relieving pain.

So after I let loose with a few ex expletives and felt better about myself, we discussed this and said, well, you know, while it may help you or the person who's cursing, are you gonna really recommend this to your patients and recognize that while it may alleviate your pain if you curse, it may cause more pain to someone else. I'm not sure where this is going, but it's nice to know, especially for you cursors out there. A cohort study of myositis patients looked at the incidence of opportunistic infections. This was a two zero four patients who had inflammatory myositis, and were followed up over time. And it turned out that, thankfully only about six percent, exactly six point four percent of patients develop opportunistic infections with a wide definition here, but obviously fungal, mycobacterial, and even viral, opportunistic infections.

And what they noted in this cohort that did get infection that more than half of them occurred in the first year. That's a really important point because that's what you see with most serious infectious events with biologic therapy. Most of these events, if they're gonna occur, usually occur in the first six months, but certainly within the first year. And that's what they saw here with these OIs, opportunistic infections. They were strongly associated with the use of high dose steroids with biologics.

Fever onset seemed to be a distinguishing feature and those patients who, had been on four or more immunosuppressors were also maybe at higher risk. So, again, it should be noted that patients with myositis are unique and do have a significantly higher rate of serious infections, And it's probably not linked only to the high use of steroids or immunosuppressants. There may be something constitutive about those patients. I think pound for pound, there may be more infections in dermatomyositis, polymyositis than there is in fact in lupus. But that study has actually not been done.

But this is I think important and something to look out for in your patients who you manage with inflammatory myositis. An interesting study comes out of Taiwan where it looks at claims data to look at hearing loss, and they looked at, over eighteen thousand patients with rheumatoid arthritis and they matched this against seventy three thousand plus non RA patients and looked for claims of hearing loss in the general population and in the RA population. They found RA patients have a twofold increase in hearing loss. It's more common in men, in older people, and it may be worse in those who have multiple comorbidities, including hypertension. They found that interestingly that almost all therapies from nonsteroidals, prednisone, biologic DMARDs, when they were used were associated with a lower rate of hearing loss, suggesting that possibly, control of disease or, control of inflammation may be associated with a lesser risk.

You might have thought that nonsteroidals would have been associated maybe with some higher rate, but in fact that was not seen. It was a lower rate. So, I thought that was a novel finding, one that you may want to look at in your RA population. An interesting study comes from the Medscape. You know, they do these annual reviews on who's the happiest physician, who makes the most money.

This particular survey by Medscape just published this last week is their 2018 physician burnout and physician depression survey. And I guess, you know, when they fish for this kind of data, you wonder how real the results are, but nonetheless, they looked at over 15,000 physicians in 29 subspecialties, medical and subspecialties and surgical subspecialties in fact, and they found that the rates range from a high around forty plus percent for some of the medical and daily care, family practice, internal medicine, etc. Specialties to as low as like in the teens for plastic surgeons and dermatologists and people who spend more time on the beach than do in the clinic. That's just a little commentary, we should probably save that. But nonetheless, when you look at the data for physicians, for rheumatologists, our rates were actually, amongst the lowest for, medical subspecialties with only thirty eight percent of rheumatologists surveyed saying that they were burnt out.

And when they looked at the number of rheumatologists who said they were both burnt out and depressed, that the number was about ten percent with the average being fourteen percent. Now, overall in this survey, they found the forty five or forty four percent of people had burnout and that, up to fifteen percent had some degree of depression. So, by comparison to the mean, we're not doing so bad. Rheumatologists, not surprisingly, again, when you ask how happy are you at work, rheumatologists, twenty seven percent of rheumatologists said they're happy at work, which put us really somewhere in the middle of the pack. We're no longer the happiest of all physicians that are out there.

Nonetheless, when it comes to analyzing why physicians are burnt out, and have these problems, it is often related to administrative tasks and bureaucratic nonsense that exists within institutions and practices. It is sort of seconded by, the number of hours that a physician works. A lack of respect by colleagues and coworkers and and the system that you're in. And lastly, not surprisingly, it's been written about before, the increasing use of computerization and the EMR EHR, contributes to the significant problems with burnout. There's a nice study that comes from the German registry called Biker.

This is a registry that has been started a few years ago excuse me and has tracked the use of biologics in the pediatric population in Germany. In this particular sub analysis, they looked at two forty five patients with systemic JIA and they specifically looked at the use of etanercept, all the IL-one inhibitors and specifically just two, anakinra, and canakinamab, and tocilizumab, and they compared how patients did on these therapies. It turns out there are actually more people treated with etanercept, one hundred and forty three, than there were with tocilizumab seventy one or the IL-one inhibitor sixty, but the IL-one, the patients who received etanercept tended to be people who had very little systemic disease. They tended to have a little bit more arthritis than the patients treated with tocilizumab and, the IL-one inhibitors, But when you looked at the outcomes and the outcomes were JDAS remission, middle disease activity, inactive disease by ACR criteria, there was a clear cut winner for both the IL-one inhibitors and tocilizumab, doubling the rates almost in some categories over etanercept. So in looking at just minimal disease activity, thirty five percent on etanercept, sixty one on tocilizumab, sixty eight percent on on the IL-one inhibitors.

IL-one inhibitors did a little bit better than tocilizumab in some of these measures, didn't look very significant. But I I think this is instructive and we know that IL-one inhibition and IL-six inhibition are certainly indicated in systemic JIA and Still's disease because they're much, much better at controlling the systemic manifestations. On the other hand, the use of TNF inhibitors are not very good at systemic manifestations but would be appropriate for patients who have articular manifestations, polyarthritis, etcetera. So, what's the deal with weight loss? A very interesting study comes from Jeff Sparks' group, in in Boston where they actually looked at one clinic, their single practice, and they had a hundred and seventy four RA patients in this practice and, sixty seven percent of them were either overweight or obese at baseline.

They defined patients as that lost weight as having a greater than five kilogram weight loss as being significant, and they defined RA improvement as a greater than five point improvement in C. Dye. So they looked at this cohort and compared patients who the obese patients who, had these changes versus those that were not obese, and those who did not have the change as well. So what they found was that the obese and overweight patients who did have, in fact, a five kilogram, 10 pound or more weight loss had a threefold increase, chance of a disease activity improvement greater than five, C. Di units compared to those who did not, that being very significant.

This is a nice result, and what's more important is this is real world. This is taken from EMR data only. So, it's a retrospective analysis. I think it's very instructive. It tells you that your counseling patients to lose weight could have immediate and tangible improvement, by these parameters.

So, how do you get there? Obviously, you need to guide the patient and certainly suggest it. Well, you might say guiding patients suggesting weight loss is futile as nobody does it, everybody pays lip service, there are a lot of studies that clearly show that the ones who do lose weight will often cite physician interaction, physician instruction as the primary reason to in fact lose weight. So what this is now important because in the last week JAMA reports a number of different articles around weight loss and specifically around bariatric surgery. So they did this very large, study, it's what's called the sleeve pass study, which compared, in 240 patients, a prospective design where patients either received a gastric sleeve where they cut away like most of the body of the, of the stomach and leave a sleeve, much like your sleeve here, that is narrow, tubular, and, sort of restricts flow and delays gastric emptying.

When they do that, they know there's a significant reduction in ghrelin and that mediates appetite, etcetera. But they compared this to the traditional Roux en Y gastric bypass surgery, which still is the gold standard in this injury, in this industry. So in their patients, they they did this study. It was a five year follow-up, and they found clearly that the bypass patients did better than the sleeve. And by all parameters, percent weight loss, diabetes remission, discontinuation of statins, discontinuation of blood pressure medicines, the morbidity rate, it's about a ten percent advantage to the bypass over sleeve, but it's not significant.

So in in percentage weight loss, it was fifty seven percent for the bypass and forty nine percent for the sleeve. So, again, these are five year results and and and encouraging. You may ask about lap band surgery. That's felt to be even more inferior to the sleeve and is falling out of favor, I believe, with a lot of people. The newer procedures such as gastric balloon are not felt to be well studied enough to, advocate for, and this sort of data is not available.

In the report that we had on RheumNow, we also talk about the STAMPEDE study, which is published in New England Journal, '13. It has a follow-up in 2015 that shows the same results that, again, sleeve sleeve is good, very good, but not as good as still the RheumY gastric bypass. That's it for this week on rheumnow.com. Go to the website. You can find the links and more information about these studies for your reading pleasure.

We'll see you next week on rheumnow.com. Make sure you subscribe on YouTube or on iTunes or on Soundhound if you like the podcast. Bye bye.