The RheumNow Week In Review - 23 February 2018 Part I Save
The RheumNow Week In Review - 23 February 2018 Part I by Dr. Cush
Transcription
It's the 02/23/2018. This is the RheumNow we can review. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com, coming to you live from Dallas. This week in the news, there's good news for patients with Behcet's, maybe a new drug.
Should you worry about your ANAs? Could they be letting you down? And who is Hyman Zimmerman and why should rheumatologists know why he's so important? There's ancient diseases that we need to manage and that's called gout. And we have a new report about this ancient disease.
That's actually an interesting anthropologic study that actually shows proof that Duke Federico of Montefeltro from the Italian Renaissance died in 1482 had gout. This is based on the analysis of his skeletal remains radiographs and even letters wherein he describes gout to a t. Again, this is an ancient disorder. It's sort of, I think, historic interest to find reports like this letting us know that that some of the things we recognize today were going on hundreds and thousands of years ago even. Gout is in the news, there's been a report, last week we had a report on gout, this week we had another report on the performance of rheumatologists in The United Kingdom.
There they actually looked at the medical records see to see if The UK rheumatologists were performing up to snuff and up to their guidelines that have been established, EULAR guidelines and their local guidelines. So what they did show was that the vast majority were doing very well with regard to guidelines starting allopurinol at a hundred milligrams, escalating, watching renal function, etcetera. But the downside was that more than half, forty five percent failed to achieve their target uric acid level of six milligrams per deciliter. I think over there it's three hundred and forty five millimeters milliliters millimoles per liter. I'm one of these days I'm gonna go metric.
I'm not likely soon. Nonetheless, what they did show is in this cohort of over four thousand three hundred gout patients, most of whom were male, only thirteen percent were crystal proven, but they did things like stopping diuretics and almost thirty percent of patients they started your rate lowering therapy in over three quarters of patients and they co prescribed prophylaxis in inhibitory therapy in over ninety percent of those that were prescribed a urate lowering drug. So they did very well, but again, a lot like the other studies, the ability of even rheumatologists to achieve a target goal, is really not that great. A lot of the studies that are out there show rates of around thirty, thirty five percent. So if these fellows are doing forty five percent in The UK, Wahoo, congratulations, but why aren't we not doing this in a hundred percent of patients?
It's not that hard. We just need to push the allopurinol dose and be more aggressive. Gout is a bad disease and it's eight times more prevalent than rheumatoid arthritis. Good news for dermatologists and those of you who follow patients with dermatologic disorders, you know, atopic dermatitis is almost as big a deal in dermatology as is psoriasis. Tends to be a big problem for which there aren't a lot of good therapies.
A lot of reports in the literature this week, I just read one today where methotrexate outperform cyclosporine and atopic dermatitis. But the good news is that the AAD meetings in San Diego occurring this week, all the new drugs, especially the JAK inhibitors are looking really, really good when it comes to atopic dermatitis. This week, the FDA granted breakthrough status to tofacitinib, Xeljanz for its proceedings in a phase three trials to get to study atopic dermatitis. So again, there's a lot of action in atopic dermatitis and a lot of it's good, especially with the new JAK inhibitors. Doctor.
Hyman Zimmerman is sort of famous in amongst FDA, and safety buffs. He's known for High's Law. High's law was based on the observation by Doctor. Hyman Zimmerman that patients who had drug induced hepatocellular liver damage, and then they also, if they had threefold to fivefold elevations of their AST or ALT and they had jaundice, he observed that ten percent of those people had a chance of dying from their liver disease. So the idea is that drug induced hepatocellular injury greater than threefold elevations with jaundice confers a ten percent mortality risk.
That's High's law. It's a standard that's used in development of all new drugs, and that's one of the outcomes they look for in new drug development as far as how bad could the liver damage be if there's a drug that may affect the liver. This is often talked about, I first heard about it looking at the FDA data on leflinomide many years ago. There's an Australian study that looked at ACL injuries amongst pediatric patients and shows that amongst kids ACL injuries have significantly grown one hundred and fifty percent in the last, few decades. It's gone from two per one hundred thousand to almost seven per one hundred thousand between, '2 thousand and '5 and twenty fifteen.
That's a ten year interval with one hundred and forty eight increased risk. The same data has actually been reported amongst American pediatricians. The question is why? Why are kids getting more ACL injuries? It could be that maybe better access to care, it could be more frequent use of MRIs, it could be the sports.
It could be obesity. There's a lot of factors that go in here. I think it's important to those of us who do manage or take care of children with musculoskeletal complaints to consider an acute cruciate ligament and internal knee derangement as a cause for a chronically swollen monarthritis or oligoarthritis. Consider it, especially since it's on the rise. There's a new study called the PANTS study.
I'm reporting it because I just like the name PANTS study. It's almost like it was dreamed up by David Letterman and you have to know David Letterman to know what that means. But it stands for personalized anti TNF therapy in Crohn's patients. It's a real world efficacy and safety trial that compared the efficacy, safety immunogenicity of the originator biologic infliximab to the biosimilar CTP-one, also known as REMSIMA or Inflectra to adalimumab in patients with Crohn's disease. Large study basically showed across the board one year results, they all had remission rates that were the same forty percent, forty percent and thirty four percent for the three drugs.
Immunogenicity is all is basically the same 26, twenty eight and eleven. So bottom line is, again, we have a lot of good data about the, use of biosimilars and they're gonna take over at some point and it's data like this that makes it more comforting to make that switch. There's a three decade study coming from the Mayo Clinic that says that there's an increase of renal stones or nephrolithiasis in the Olmsted County population and it was basically looking at both symptomatic and asymptomatic nephrolithiasis and they showed that amongst men there was a fourteen percent per five year, increase. There was, every five years in women there was a twenty nine percent increase and this is again over a thirty year period. The question is why?
Well, it's the same reason as to why the frequency of gout has gone up. It has to do with the obesification of our society, has to do with wider use of diuretics and renal disease, and it may have something to do with changes as well. So this is a sort of epidemiologic issue that
Should you worry about your ANAs? Could they be letting you down? And who is Hyman Zimmerman and why should rheumatologists know why he's so important? There's ancient diseases that we need to manage and that's called gout. And we have a new report about this ancient disease.
That's actually an interesting anthropologic study that actually shows proof that Duke Federico of Montefeltro from the Italian Renaissance died in 1482 had gout. This is based on the analysis of his skeletal remains radiographs and even letters wherein he describes gout to a t. Again, this is an ancient disorder. It's sort of, I think, historic interest to find reports like this letting us know that that some of the things we recognize today were going on hundreds and thousands of years ago even. Gout is in the news, there's been a report, last week we had a report on gout, this week we had another report on the performance of rheumatologists in The United Kingdom.
There they actually looked at the medical records see to see if The UK rheumatologists were performing up to snuff and up to their guidelines that have been established, EULAR guidelines and their local guidelines. So what they did show was that the vast majority were doing very well with regard to guidelines starting allopurinol at a hundred milligrams, escalating, watching renal function, etcetera. But the downside was that more than half, forty five percent failed to achieve their target uric acid level of six milligrams per deciliter. I think over there it's three hundred and forty five millimeters milliliters millimoles per liter. I'm one of these days I'm gonna go metric.
I'm not likely soon. Nonetheless, what they did show is in this cohort of over four thousand three hundred gout patients, most of whom were male, only thirteen percent were crystal proven, but they did things like stopping diuretics and almost thirty percent of patients they started your rate lowering therapy in over three quarters of patients and they co prescribed prophylaxis in inhibitory therapy in over ninety percent of those that were prescribed a urate lowering drug. So they did very well, but again, a lot like the other studies, the ability of even rheumatologists to achieve a target goal, is really not that great. A lot of the studies that are out there show rates of around thirty, thirty five percent. So if these fellows are doing forty five percent in The UK, Wahoo, congratulations, but why aren't we not doing this in a hundred percent of patients?
It's not that hard. We just need to push the allopurinol dose and be more aggressive. Gout is a bad disease and it's eight times more prevalent than rheumatoid arthritis. Good news for dermatologists and those of you who follow patients with dermatologic disorders, you know, atopic dermatitis is almost as big a deal in dermatology as is psoriasis. Tends to be a big problem for which there aren't a lot of good therapies.
A lot of reports in the literature this week, I just read one today where methotrexate outperform cyclosporine and atopic dermatitis. But the good news is that the AAD meetings in San Diego occurring this week, all the new drugs, especially the JAK inhibitors are looking really, really good when it comes to atopic dermatitis. This week, the FDA granted breakthrough status to tofacitinib, Xeljanz for its proceedings in a phase three trials to get to study atopic dermatitis. So again, there's a lot of action in atopic dermatitis and a lot of it's good, especially with the new JAK inhibitors. Doctor.
Hyman Zimmerman is sort of famous in amongst FDA, and safety buffs. He's known for High's Law. High's law was based on the observation by Doctor. Hyman Zimmerman that patients who had drug induced hepatocellular liver damage, and then they also, if they had threefold to fivefold elevations of their AST or ALT and they had jaundice, he observed that ten percent of those people had a chance of dying from their liver disease. So the idea is that drug induced hepatocellular injury greater than threefold elevations with jaundice confers a ten percent mortality risk.
That's High's law. It's a standard that's used in development of all new drugs, and that's one of the outcomes they look for in new drug development as far as how bad could the liver damage be if there's a drug that may affect the liver. This is often talked about, I first heard about it looking at the FDA data on leflinomide many years ago. There's an Australian study that looked at ACL injuries amongst pediatric patients and shows that amongst kids ACL injuries have significantly grown one hundred and fifty percent in the last, few decades. It's gone from two per one hundred thousand to almost seven per one hundred thousand between, '2 thousand and '5 and twenty fifteen.
That's a ten year interval with one hundred and forty eight increased risk. The same data has actually been reported amongst American pediatricians. The question is why? Why are kids getting more ACL injuries? It could be that maybe better access to care, it could be more frequent use of MRIs, it could be the sports.
It could be obesity. There's a lot of factors that go in here. I think it's important to those of us who do manage or take care of children with musculoskeletal complaints to consider an acute cruciate ligament and internal knee derangement as a cause for a chronically swollen monarthritis or oligoarthritis. Consider it, especially since it's on the rise. There's a new study called the PANTS study.
I'm reporting it because I just like the name PANTS study. It's almost like it was dreamed up by David Letterman and you have to know David Letterman to know what that means. But it stands for personalized anti TNF therapy in Crohn's patients. It's a real world efficacy and safety trial that compared the efficacy, safety immunogenicity of the originator biologic infliximab to the biosimilar CTP-one, also known as REMSIMA or Inflectra to adalimumab in patients with Crohn's disease. Large study basically showed across the board one year results, they all had remission rates that were the same forty percent, forty percent and thirty four percent for the three drugs.
Immunogenicity is all is basically the same 26, twenty eight and eleven. So bottom line is, again, we have a lot of good data about the, use of biosimilars and they're gonna take over at some point and it's data like this that makes it more comforting to make that switch. There's a three decade study coming from the Mayo Clinic that says that there's an increase of renal stones or nephrolithiasis in the Olmsted County population and it was basically looking at both symptomatic and asymptomatic nephrolithiasis and they showed that amongst men there was a fourteen percent per five year, increase. There was, every five years in women there was a twenty nine percent increase and this is again over a thirty year period. The question is why?
Well, it's the same reason as to why the frequency of gout has gone up. It has to do with the obesification of our society, has to do with wider use of diuretics and renal disease, and it may have something to do with changes as well. So this is a sort of epidemiologic issue that
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