The RheumNow Week In Review - 2 March 2018 Save

Hi, it's 03/02/2018. I'm Doctor. Jack Cush, executive editor of roomnow.com, and this is the Room Now Week in Review. This week we've got news about gout and what saves lives. We've got news on natural products that actually work and a new way to diagnose myositis.

At the top of the news, we have a report about FDG PET scanning and its utility in patients with large vessel vasculitis, things like tachyassus and giant cell arteritis, was actually subjected to, a number of patients. And what they found in this analysis was that it had an 85% sensitivity and 85%, 83% specificity. Moreover, that when the PET was repeated during the time the patient was in clinical remission, it was shown that an abnormal PET had the fivefold more likelihood of predicting a relapse, relapse, meaning that fifty five percent of such patients would relapse, but only eleven percent with a negative scan would relapse. So that was sort of good news. I don't know about you, but I have a few Takayasu's patients who have intermittent blips in their CRPs, and it's hard to assess what their status is just based on the serologies and based on the exam, and you have to resort to imaging, I think this might be a better way than doing MRAs or CTAs.

An interesting review of viscosupplementation of the hip shows that it does not work. Now, don't know where you've been, if you've been doing viscosupplementation. Is it something you do while you're waiting for the patient to get better on their own? But it doesn't work. Are certainly there are patients who swear by it and I'm sure that they like it, but, the overwhelming evidence is that this does not produce better outcomes when you look beyond three months and six months and whatnot.

So it's been shown for the hip and it's also been shown for the knee. Why these are used? Again, it's something to do when you don't know what else to do. An interesting study of two zero one osteoarthritis patients assessed the efficacy of curcumin combined with boswellic acid or Boswellia, another natural product often purported to have some effect in patients with arthritis. Again, those are very vague.

Again, those who are interested in nutritional products seem to like this combination or these products. But nonetheless, this was studied in two zero one OA patients in a double blind placebo controlled randomized fashion and shown to be effective. So I certainly know that turmeric and curcumin do have benefits. It's been shown many times before in osteoarthritis, but now combined with buspiric acid may be another option for those who don't want to take other forms of analgesic therapy. A new study shows that inflammatory myositis may be associated with anti mitochondrial antibodies.

I don't usually do anti mitochondrial antibodies, but the study suggests that there might be a role for it. Specifically, the finding of anti mitochondrial antibodies seems to be associated with a higher risk of severe cardiac involvement. Moreover, those are nailing this is a case report for a series of seven patients, so it's not a large number here. But nonetheless, you know, half of these people had necrotizing myopathy and almost half of them had other autoimmune diseases such as psoriasis, PBC, and Hashimoto's thyroiditis. So again, in the spectrum of laboratory testing that may want to accompany a new diagnosis of inflammatory myositis, it may be prudent to include anti mitochondrial antibody testing.

A very interesting study comes from BEST. BEST is the study that just never seems to stop giving. As you know, BEST was a 500 patient study that analyzed the comparative efficacy and safety of four different regimens in treating rheumatoid arthritis patients, early rheumatoid arthritis patients. What they did in this particular sub study of BEST was they looked at those patients who had DIPs and PIP joint involvement, And they then looked at whether or not TNF inhibition affected x-ray outcomes. And what they showed was that being on a TNF inhibitor was associated with less progression of DIP joint osteoarthritis and presumably less de novo or new incipient osteoarthritis than DIP, but did not have a protective effect on the PIP joints.

So what they showed was 2.3 less DIP involvement for every month of TNF inhibitor treatment that was used. I think that's surprising. It says a lot about the secondary benefits of TNF inhibitor therapy in RA patients. We do know that inflammatory disease is a predisposing feature for, degenerative disease. It may also say a lot about the idiopathic genesis of degenerative disease, especially in the DIP joints, and may merit further consideration.

Now, you know, there are studies that also have looked at TNF inhibitor used in patients with erosive inflammatory OA and have not been shown to be effective. So again, take it for what it is. It's a benefit, for your patients who are on TNF inhibitors. Another interesting study comes as a case series of one hundred and thirty four patients treated with rituximab and specifically looked at the development of hypogammaglobulinemia. They found this to occur in twenty three of their one hundred and thirty four patients or seventeen percent And that's after a mean of sixty four months of therapy.

What they did find was that of that seventeen percent, those people had a fourfold greater risk of severe infections, not nonsense infections, but severe infections. So the takeaway on this was that the baseline gamma globulin level, gamma globulin levels of less than eight grams per liter was associated with future development of hypogammaglobulinemia. That's also been shown by the study by Ron Van Vollenhaven that's looked at the risk of severe infections and showed that it was largely the starting out with a low IgG level was most predictive of developing severe infections and associated with rituximab use. And that was in patients who received nine or 10 different courses of therapy. A new report comes from the orthopedic literature where they looked at hip replacement in the Swedish registry of hip replacements.

So they studied in Sweden one hundred and thirty one thousand plus patients undergoing total hip arthroplasty. And when they compared that to patients that were age and sex matched, they found that survival of patients undergoing hip arthroplasty was one percent greater one year after surgery compared to those who did not. And it was three percent greater at five years compared to those who did not. The benefit of longevity and survival was lost when you looked at twelve years. So was a benefit of survival that lasted at least ten years.

And that this benefit was significant only for patients with primary osteoarthritis as their background problem. Worse outcomes were obviously were seen with hip replacements as far as survival in patients who had inflammatory osteoarthritis, patients who had inflammatory arthritis like rheumatoid arthritis, and interestingly patients who had avascular necrosis of the femoral head. A new study on gout showed by Nicola Dalbeth and Hian Choi and colleagues looked at an analysis of one hundred and fifty two patients in Australia and I guess it was New Zealand and The United States, and they looked at patients who are on allopurinol and they followed these patients for over five years and they found that of the patients on allopurinol, seventy percent of them still had evidence of crystal deposition on dual energy CT scanning. That's deck scanning that gives you those nice bright lime green deposits that are quantifiable in the deep tissues. More importantly, for patients that were on Alapuram and had achieved their target uric acid level of less than six, they still found crystal deposition by dec in half the patients.

But if you did not achieve your target goal of six or less, in fact, so if it was more than six, ninety percent of patients had evidence of tissue deposition of deck. Now they did deck scans in the hands and feet and ankles. They didn't do total body decks. They might have different results if they did total body deck scanning, but this is interesting. It says that, you know, even if you don't have palpable tophi, you still may have deep tissue deposition of crystals.

Another study about gout looks at the benefits of probenecid on the heart. You may know that from past reports here that chronic therapy with either colchicine or with allopurinol reduces overall cardiac event rates and even cardiac survival. This report looked at the benefits of probenecid in patients who had gout, and they studied their heart function. They actually did some in vitro animal studies, to look at myocyte function. Function.

What they do know is that probenecid has a positive ionotropic effect, hard word for rheumatologist, rheumatologist is a hard word for rheumatologist, ionotropic effect on the cardiomyocyte It does so by affecting, ion channels. These are transmembrane channels, what's called a TRPV, the transient receptor potential vanilloid two, channel that is involved in calcium signaling transmembrane wise, and that actually has an effect on the heart. What they showed was that patients who were on probenecid, they had an increase in myocardial function even after one month of therapy. So again, the mechanism by which probenecid may benefit the heart is maybe very different than just simple uric acid lowering, which is what happens with allopurinol. So that's good news for patients with gout and maybe a reason to revive an old fashioned drug that's seldom used probenecit.

Lastly, there's a report about IL-eighteen binding protein in adult onset Still's disease. This is a new biologic called Tadekinig. Tadekinig Alpha comes in eighty milligrams, one hundred and sixty milligrams. They treated ten and thirteen patients prospectively, open label, increase the dose, drug is given three times a week for twelve weeks, and it shows significant clinical benefits, loss of fever, correction of many of the systemic abnormalities seen in adult onset Still's disease. IL-eighteen binding protein has been talked about for quite a while.

Now we have that as a therapeutic option. New trials are going forward in this area and this will probably compete with inhibition of IL-one and IL-six as a potential new therapy for patients with systemic JIA and adults with Still's disease. That's it for this week in RheumNow. Go to the website, find the links, read more about these interesting articles. Be sure to subscribe to us on whatever channel you're looking at or listening to.

Thanks very much. Goodbye. See you next week.