The Rheumnow Week in Review - 22 September 2017 Save

Hi. I'm Jack Cush, executive editor of rheumnow.com. It's the 09/22/2017, and this is the RheumNow we can review. This week in the news, we have celebrities with rheumatic conditions. We have, mortality being really, really high in interstitial lung disease, and, what to do when you have IgG4 related disease.

At the top of the news, we have a study from the Framingham Foot study. I never I know about the Framingham studies, I didn't know there was a Framingham Foot study. It turns out this is a prospective study of over 2,000 patients followed for a number of parameters, and in this particular report that comes from a podiatry journal, they showed that those who have bilateral pain in the feet have a increased odds of having, hip and knee problems and hip and knee pain. This sort of seems intuitive that, you know, the leg bone is connected to the hip bone, is connected to the foot bone, but, you know, at the same time, I think it tells us that you should be looking to hip and knee problems when dealing with patients who do have, predominantly foot pain. In those individuals who had ipsilateral, foot pain, that was associated with, ipsilateral hip pain but not knee pain, and this was mainly seen in men, whereas the prior finding of bilateral foot pain, was seen in men and, women.

An interesting study comes from Susan Goodman and a number of researchers from a number of different sites, a sort of multinational study, where they surveyed about 200 individuals, most of whom were taking glucocorticoids and a minority of whom who were not. And they try to get a feeling of patients' impressions about glucocorticoids, and not surprisingly, said steroids really help a lot. And they even knowing all the side effects of steroids, patients were uniform in their belief that, the benefits far outweighed the, risks and the toxicities. Yet, in this study, they noted that patients who are on glucocorticoids had a lot of toxicities, including thin skin. And these are the ones that they worried about the most of all the toxicities included thin skin, easy bruisability, poor sleep, alteration of mood, and face size growing or the moon face associated with steroid use.

So it is a double edged sword. It's a great drug, but it's got side effects. Patients will put up with it. It's up to us to sort of educate them about the hazards of steroids, and like Peter Merkel said, it's the best drug and the worst drug that we have. I don't put anybody on steroids unless I tell them, listen.

It's a great drug. But if you take it a long time at a high dose, you're gonna get trouble. You're gonna get fat, diabetic, stretch marks, easy bruisability, cataracts, stomach ulcers, weird infections, common infections, bizarro infections, more infections, higher cardiovascular risk. I mean, go on and on including fractures and osteoporosis, and yes, patients at that point are motivated to get off the drug, but you need to have this approach, I think, when using steroids. An interesting review in current rheumatology looked at drug adherence, and their summation about drug adherence in rheumatic diseases is really astounding.

It says that drug adherence, non adherence, is as high as seventy four percent in egg closing spondylitis, ninety percent in gout, fifty percent in psoriatic arthritis, seventy five percent in lupus, and eighty two percent non response or non adherence rate in rheumatoid arthritis. Now, again, they say these are as high as it goes, and they review, multiple studies that have looked at these incidence rates. And, again, they're higher than you would expect. I've written before about the Consumer Reports review on this that said that, in primary care, less than half of patients who get a new prescription will fill the prescription. That's half the battle.

And then the other half is getting them to take the pay take the medicine. This is a gigantic problem. This is we're not helped by being in the dark about patient compliance. I don't know why it's not a law, rule, or mandate that managed care doesn't give us feedback about patients and their adherence to the medicines we prescribe. With that information in hand, we would be better at working on the patients who need the most help and understanding why they should be on these medicines.

Again, this is an educational gap, this is a trust gap, this is a patient reluctance to take medicine problem. So, again, it's something that's pervasive, throughout rheumatology and throughout medicine. An odd study showed up in the literature about statins and lupus. I didn't know there was an issue with statins and lupus, and I think that they were trying to look at whether chronic statin use in individuals over the age of 40 years of age might be associated with an increased risk of lupus or drug induced lupus. Turns out that that was not the case.

But they did show that patients who were on statins for greater than twelve months had a thirty eight percent lower risk of developing lupus. Of course, these are people over age 40, and lupus over age 40 is a strange phenomenon. There's a lot of misdiagnosis. There's a lot of drug induced lupus. There's a lot of serologies that's called lupus.

So I'm not sure what the utility of this information is, and I really am not too sure about the protective effect of statins in lupus, but you might want to, look at that report and think about it. An interesting report comes from Rob Schmerling and the group at Harvard, and, they looked at polyarticular versus monarticular septic arthritis. In fact, they had four sixty four cases. This is a retrospective review. Four hundred sixty four cases of polyarticular septic arthritis versus forty two monarticular.

And they showed that between the two, there were a lot of similar outcomes. Septic arthritis is not very good. But they did show that those who had polyarticular disease were more likely to have pre existing rheumatoid arthritis, have much higher synovial fluid white blood cell counts, and longer hospital stays. Not surprising that polyarticular disease would have a rockier course or maybe a worse disease, than monarticular disease. Another survey came, along recently looking at pediatric nephrologists versus pediatric rheumatologists on the issue of membranous lupus nephritis and how it's managed.

What the survey showed was that, the nephrologists were less likely to use steroids than the rheumatologists, sixty versus ninety three percent. And then mycophenolate was less likely to be used by the nephrologists than the rheumatologists, fifty three versus eighty seven percent. And again, these are patients who don't have nephrotic syndrome. So rooms are pretty quick to treat membranous disease and the nephrologists are sort of holding back because not every case of membranous disease will actually need treatment and can be observed provided they don't get into trouble with their nephrotic syndrome or other manifestations of their nephritis. A longitudinal study of one hundred and seventeen RA patients examined what the influence of fibromyalgia was.

And in this study, they showed that seventeen percent of patients who had fibromyalgia in addition to their rheumatoid arthritis were less likely to achieve a substantial clinical response. In fact, remission rates were significantly less compared to those who didn't have fibromyalgia. They actually had, more pain and comorbidity big surprise there and significant problems with sleep and higher SF-thirty six MCS mental component scores. So again, fibromyalgia will complicate, rheumatoid arthritis. If you're doing clinical trials, you should make an effort, to exclude fibromyalgia patients from an RA trial.

It really will, skew the results and make data interpretation very difficult. An interesting study came along this week about the use of injections versus splinting in patients with carpal tunnel syndrome. Fifty patients each were, and this was not a blinded study, but it was a randomized trial of steroid injections or carpal tunnel. And while many of the results were the same, there was better dexterity and better patient satisfaction with the injection. So I think this says that, you know, patients who are reluctant to have injections might do very well with aggressive splinting, especially when you're looking at, outcomes twelve months later.

Two celebrities in the news. This is kind of People Magazine kind of reports, you know what? Your patients are going to talk about this, and you need to be conversant with the fact that Selena Gomez, young pop star, ex girlfriend of Justin Bieber, don't ask me why I know that, has lupus. Now, we've known that for a while, and you wonder, well, what kind of lupus? Well, she actually recently had a renal transplant, and she's gone through it.

She's survived it. She got this renal transplant from her assistant or best friend, and every you know, it's a happy ending at this point. The status of her lupus is really unknown, but it's been widely publicized. It was in People Magazine and Wall Street Journal and other news sources, and I think it's important to note. Lady Gaga, another famous singer, came out recently and says that she has fibromyalgia.

She recently canceled several of her concerts, because of her fibromyalgia and says that she intends to shine a light on fibromyalgia, she's going to make a video about it, and I think it's a good thing. Patients can identify with people who have the same disease. Other recent reports that we found from the literature, mortality being increased in patients with interstitial lung disease. Not surprising, ILD is a bad outcome, an extra articular outcome in rheumatoid arthritis, long standing disease, high titer seropositivity is the profile of people who are going to have ILD. Six seventy nine patients with RA and ILD were compared to, I think, twelve thousand RA patients without ILD.

In general, the mortality figures, whether it's one year or five years or ten years, are about double when you look at those who have ILD. The one year mortality was thirteen point nine versus three point eight, those with and those without ILD. The ten year mortality was sixty percent with rheumatoid lung and thirty four percent without rheumatoid lung. Ten year mortality of rheumatoid arthritis without any lung disease, one third? I'm not sure who these patients are but I would like to think we're doing better than that.

But it does speak to the seriousness of finding ILD and the need for therapies. Our best therapies, which are great at the joints, are not very good at managing any of the extra articular manifestations of RA, and that includes ILD and vasculitis and nodules and Sjogren's, etcetera. A New England Journal report this week on Romexizumab, the anti sclerosan drug, in a clinical trial was two twelve, twenty four months long. And the design of the trial were patients were randomized and these are patients who have high risk for fracture, who have osteoporosis. Everyone was randomized to either receive Romecizumab, monthly injections versus weekly, Fosamax for one year, and then in the second year, everyone received, Fosamax or alendronate.

It was shown that the induction, if you will, with the anti sclerosan drug was associated with significant reductions in fracture rates. All fractures, nonvertebral fractures. Again, I think that the results were pretty astounding. This is four thousand patients. The only downside here was that there was a higher rate of cardiovascular events than those who received Romecizumab.

And this is, one of the adverse events that the FDA was worried about when it issued a, complete response letter halting the approval of Romecizumab, and the FDA asked the manufacturers, which is, Amgen and UCB, to come back with, new information from this trial and other trials about safety and other other matters. So the jury's still out about if and when ramucizumab will be approved. Seems to be a great drug, but there's a small issue of, cardiovascular risk. And why that would be remains to be seen. Lastly, an interesting report looks at the utility of rituximab in patients with IgG three no, IgG four is like two twenty, two twenty one, whatever it takes.

Look it up. IgG four related disease where, you know, we're just starting to know how to identify these patients, how to diagnose them. There's criteria. There's a number of trials out there, none controlled. The high dose steroids is sort of uniform.

DMARN therapy with Imuran, mycophenolate, and even rituximab. In this French experience, I think they had a hundred and fifty IgG4 related patients in their cohort, thirty three of whom were treated with IV rituximab, and they showed very high response rates with, I think, over ninety percent, thirty one out of the thirty three responding, initially and with low low relapse rates when, therapy was not continued and the B cell numbers were reconstituted, relapses would resume. So it turns out that these patients should be treated with rituximab, but at least this is not a good option or the setup for a good randomized trial of maybe mycophenolate versus rituximab in patients after they receive receive steroids. But these are good options and good data. That's it for this week at roomnow.com.

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