The RheumNow Week In Review 24 March 2017 Save
The RheumNow Week In Review 24 March 2017 by Dr. Cush
Transcription
Hey now. It's the 03/24/2017, and this is the RheumNow we can review. I'm doctor Jack Cush, executive editor of roomnow.com, coming to you from Dallas today where we're going to tell you about the big news in rheumatology. At the top of the news, actually, there's three big things that really stand out for me. The New England Journal has featured two articles about rheumatology, specifically a review of psoriatic arthritis and an article about pregabalin or Lyrica.
There's also new treatment guidelines from the Sjogren's Foundation, but are they good enough? And lastly, there's an article about smoking that leads to poor outcomes in patients undergoing arthroplasty. From our social feed this week, there's a New England Journal article that we, posted today, published yesterday about pregabalin or Lyrica being ineffective in a randomized controlled trial of two zero nine patients with, either acute or chronic sciatica pain. It turns out that pregabalin was actually equal to placebo and didn't have much of an effect, either at eight weeks or at one year. And that more interestingly, there was certainly a lot more, side effects and adverse events in those who were taking the Lyrica.
Again, there is probably a role for Lyrica and management of pain, but it's not always as good as we'd like it to be. Good news for Amgen, it's biosimilar called Amjevita, which is a biosimilar of adalimumab has actually been approved by the EMA in the European Union for use in adults and children with inflammatory disorders like JIA and pediatric Crohn's and, of course, rheumatoid, psoriatic, spondyloarthritis, etcetera. So that's good news on the biosimilar front. There's an interesting small study of 23 HIV patients taken from four centers who were also taking HIV inhibitors. They reviewed whether or not they were at higher risk for serious infections.
Turns out that they were not. Interesting in that, well, you think TNF inhibitors cause infections, here's a high risk group, and they were not shown to cause infections. Of course, there was a historic control here rather than active control, but it is nonetheless important. One, to show that you can use TNF inhibitors in HIV patients without any additional risk, two, that they're safe in those patients without any risk of serious infections. I don't know about you, but I came across some very disturbing little bit of information.
It's been out there a long time, but I was unaware, and you should talk to your drug rep about this. But every time a drug rep hands you a reprint, you're being charged for it. It goes on your Sunshine Act reporting list. And again, how much you're being charged for it, you should find out. So is it worth it?
It's up to you. You might be able to download it for free and not be look like a standout on the Sunshine Act list. There's a very good study that was done by, Jeff Curtis and colleagues that looked at the protection offered by, the zoster vaccine, in patients with immune mediated or, autoimmune diseases. In a very large cohort, again, is claims data of fifty nine thousand six hundred and twenty seven patients, they showed that in the first year, was forty four percent less events of herpes zoster and that, this lasted for as long and was significant for as long as five years with the numbers being twenty three percent less at five years. These numbers are about similar to that seen in the regular population where, again, fifty percent protection was conferred by, the zoster vaccine in the general population.
So good news for your patients who, have autoimmune disease and need that vaccine. A nice study looked at colored Doppler ultrasound in assessing, vascular changes in seventy nine patients with systemic sclerosis. They compared this to, normal nail hole capillaroscopy and other findings. They showed that abnormalities of colored Doppler ultrasound was associated in those who had high CRP levels, those who had a greater than twenty pack year smoking history, males, and those who had either digital pulp ulcers or digital pulp scars. This could become a useful tool in the assessment and management of patients with microvascular disease like that seen in scleroderma.
A small review of forty six patients, in India were taking methotrexate and develop pancytopenia. I think it's somewhat instructive. What they found in that population was that this did occur at a mean low dose of ten milligrams per kilogram I'm sorry, ten milligrams per week. But the main onset symptoms were that of severe mucositis and fever. And those that were at risk were those who had a low albumin, those who had renal failure, and more importantly, that amongst these, forty six patients, thirteen died.
So this is a highly, deadly event, that can be avoided by monitoring renal function and patients who are on the drug. A report from last week's AAOS meeting shows that smoking cessation prior to, a knee or hip arthroplasty actually improves outcomes. So those who are taking, who who are smoking prior to surgery actually had worse outcomes and more complications than those who actually had ceased. So, good instruction for your patients who are undergoing arthroplasty. A small but interesting report looked at, the rare occurrence of inflammatory bowel disease occurring in systemic juvenile arthritis patients, Still's disease patients, who and when it did was seen in this Israeli cohort of eighty one patients, the three cases that were seen, very low number, were all unified and that they were taking interleukin one inhibitors.
And, again, that's generally not a part of the spectrum of disease seen in Still's disease. I I I know adults very well, and I've seen many children with this, and IBD is not a common it's a very rare event. And the question that whether or not the associated with IL-one inhibition is even more quizzical. If you look at the data on IL-one and IBD suggest that maybe IL-one could be a useful therapy in patients with inflammatory bowel disease. So we'll look at the literature in the future and see if this crops up more, but I think it's an important report, especially for those of you who take care of patients with systemic JIA or adult onset Still's disease.
A systematic review of over 1,200 patients who were undergoing either hip or knee arthroplasty and were under the age of 55 showed that with a ten year follow-up, a very high degree of satisfaction and of eighty five percent or more and only about five percent revision rate suggesting that this may be a good population to do surgery. Again, it's always been suggested that patients who need hip and knee replacement should wait until the last possible moment or are much older. These new arthroplasties have always been said the last ten to fifteen years, but in fact, they're really built to last thirty years when properly managed, in the current, system, that we take care of patients. So again, trying to persuade your patients who are 55 to not have surgery may not be a good idea because there's a significant degree of success there. Again, the longevity of the implant would still be the issue and the study wasn't long enough to answer that question.
Rheumatic manifestations of the chikungunya virus was recently reviewed by Cassie Calabrese in a nice article that looks at the experience of infections followed in a French cohort in what's called the Rheumatochic study. That's right, Rheumatochic. Sounds like either an all female rheumatology faculty or some sort of new study group that won't let me in. Women are taking over rheumatology. Has always been an old white guy disease, but the new numbers on people going into rheumatology, the younger generation, it's going to be sixty percent female in the next decade.
I digress. This particular study actually looked at three zero seven patients and the cumulative experience that was seen there. Interestingly, the mean, number of joints seen at presentation was 6.5. So this is a polyarticular presentation that is symmetrical, and and over eighty percent of them have persistence of symptoms going out several years. So, again, this is gonna become a, I think, a larger, number in with time.
A lot of these mosquito borne infectious arthritities are cropping up in addition to the Zika virus. We have this now, the chikungunya, being added to also dengue. But then again, chikungunya and Zika are going to be a big issue in the future. What we really don't know is how to best treat them. Right now, they're getting the best anti inflammatory therapies that we usually would use for a symmetric chronic polyarthritis.
But the outcomes of that is right now not known. Last week, the New England Journal published a review article from, Chris Richland and Daphne Gladman and Robert Koller who, they have a really good article, you should take a look at it. It gives out the numbers that we all should know that thirty percent of patients with psoriasis will likely develop psoriatic arthritis. The prevalence numbers are somewhere between six and twenty five per ten thousand, at least in The United States. They review the comorbidity issue, the use of the Caspar criteria.
Dactylitis, is seen in half the patients. Erosions develop in half the patients within the first two years. They also talk about, the childhood onset of psoriatic arthritis where there's two types, the oligoarticular subset that is often has dactylitis and maybe ANA positive with a risk of uveitis, or the late onset group between ages six and 12 who have HLA B27 and a related enthesopathy, dactylitis, enthesitis, nail changes, some of them go on to develop one of the forms of spondyloarthritis or the undifferentiated form. A really nice review of the etiology and pathogenesis that's definitely worth the read. Found a nice article this week in the American Journal of Medical Sciences that reviews lupus hepatitis and leupoid hepatitis.
There's maybe some confusion between the two, but lupus hepatitis is the development of transaminitis and hepatitis in patients with lupus, whereas leupoid hepatitis was described in 1959, and is the same thing as, what we now call autoimmune hepatitis. They both are unified in the fact that they are associated with ANA positivity and hypergammaglobulinemia, and a response to need for immunosuppressive therapy and steroids, but they can be distinguished from each other. Up to half of patients will have some kind of liver abnormalities with their lupus and transaminitis is seen in a quarter of patients with lupus. On the other hand, autoimmune hepatitis, nearly a quarter of those patients meet criteria for lupus. So again, there can be some confusion.
In the review article, I think the main standouts, as far as distinguishing between the two could be that in lupus, you obviously develop low complements and anti ribosomal P antibodies, and you generally don't see that in autoimmune hepatitis or leupoid hepatitis. On the other hand, leupoid hepatitis, just like lupus, has a high degree of ANA positivity but has different autoantibodies including the, anti smooth muscle antibodies and the anti LKM antibodies. So a nice review, probably worth taking a look at. Also, a nice article from Len Calabrese and, doctor Bingham, in ARD and also featured on Medscape reviews a lot of the features that we see with the use of these new checkpoint inhibitors. These are drugs that target PD-one such as, pembrolizumab and nivolumab, and then CTLA-four, and that's ipilimumab.
These are used for skin cancer, melanoma, solid tumors. Again, very popular agents these days even being advertised on television, but they have been associated with autoimmune inflammatory phenomenon. Going to do a Bing keynote address at the SOTA meeting, the state of the art meeting the ACR is having coming up in April. You should look at that, we advertise that on our website. He's going to review these findings of what you see many autoimmune things, including thyroiditis and lymphoproliferative diseases and myasthenia gravis and hypophysitis, but the rheumatic disease manifestations include things like SWEET syndrome, Stevens Johnson, colitis, inflammatory arthritis, and sickest symptoms are really quite common.
So, you should also know that myositis and muscle involvement, even rhabdo has been reported. So, again, looking for these findings in patients taking these specific, chemotherapeutic drugs, should be, something to consider, going forward. Lastly, there's a nice new article about the Sjogren's Syndrome Foundation, and its new twenty seventeen treatment guidelines for Sjogren's Syndrome. This is an article published by Steve Parsons and a number of experts in the field. I have to applaud them for coming out with this.
It sort of puts on the map things for us to consider, especially when looking at the use of biologics in the management of disease, looking at the treatment of fatigue, and also looking at the treatment of inflammatory musculoskeletal pain. I think many of the guidelines they put forth, 19 recommendations specifically, are instructive, including saying that really there's no role for TNF inhibitors in the management of Sjogren's syndrome, that there might be a role of the use of rituximab in really difficult Sjogren's syndrome patients, such as those with cardioglobulinemia and vasculitis or vasculitis alone, severe parotid swelling, pulmonary disease or peripheral neuropathies and modern neuritis. But I think they're a little bit suspect, some of these guidelines, in my opinion, when it comes to, for instance, recommending rituximab for the use of xerostomia. Although the committee recommended it, there's very weak evidence to support it. Also, they also suggest that hydroxychloroquine may be useful in treating the fatigue of Sjogren's syndrome, again, citing weak evidence.
And then lastly, when talking about the treatment of inflammatory musculoskeletal pain, they go through the algorithm of using hydroxychloroquine first, then methotrexate, then both, and then if not that, using either leflinamide, sulfasalazine, azathioprine, or cyclosporine, all either moderate, which I find hard to believe, or weak evidence for those. So while I like the guidelines and I like the discussion that they'll create, I think there needs to be more discussion about this to know whether this is the way to go in managing your patients with Sjogren's. That's it for this week at roomnow.com. Be sure to go to the website to tune in for more news and information. Sign up, register, you'll get daily good information from us.
We'll give you Friday and I'm sorry, Saturday and Sunday off. But Monday through Friday, good news like this. You can go to the website and find the citations as well. That's it for this week. Enjoy your weekend.
Hi.
There's also new treatment guidelines from the Sjogren's Foundation, but are they good enough? And lastly, there's an article about smoking that leads to poor outcomes in patients undergoing arthroplasty. From our social feed this week, there's a New England Journal article that we, posted today, published yesterday about pregabalin or Lyrica being ineffective in a randomized controlled trial of two zero nine patients with, either acute or chronic sciatica pain. It turns out that pregabalin was actually equal to placebo and didn't have much of an effect, either at eight weeks or at one year. And that more interestingly, there was certainly a lot more, side effects and adverse events in those who were taking the Lyrica.
Again, there is probably a role for Lyrica and management of pain, but it's not always as good as we'd like it to be. Good news for Amgen, it's biosimilar called Amjevita, which is a biosimilar of adalimumab has actually been approved by the EMA in the European Union for use in adults and children with inflammatory disorders like JIA and pediatric Crohn's and, of course, rheumatoid, psoriatic, spondyloarthritis, etcetera. So that's good news on the biosimilar front. There's an interesting small study of 23 HIV patients taken from four centers who were also taking HIV inhibitors. They reviewed whether or not they were at higher risk for serious infections.
Turns out that they were not. Interesting in that, well, you think TNF inhibitors cause infections, here's a high risk group, and they were not shown to cause infections. Of course, there was a historic control here rather than active control, but it is nonetheless important. One, to show that you can use TNF inhibitors in HIV patients without any additional risk, two, that they're safe in those patients without any risk of serious infections. I don't know about you, but I came across some very disturbing little bit of information.
It's been out there a long time, but I was unaware, and you should talk to your drug rep about this. But every time a drug rep hands you a reprint, you're being charged for it. It goes on your Sunshine Act reporting list. And again, how much you're being charged for it, you should find out. So is it worth it?
It's up to you. You might be able to download it for free and not be look like a standout on the Sunshine Act list. There's a very good study that was done by, Jeff Curtis and colleagues that looked at the protection offered by, the zoster vaccine, in patients with immune mediated or, autoimmune diseases. In a very large cohort, again, is claims data of fifty nine thousand six hundred and twenty seven patients, they showed that in the first year, was forty four percent less events of herpes zoster and that, this lasted for as long and was significant for as long as five years with the numbers being twenty three percent less at five years. These numbers are about similar to that seen in the regular population where, again, fifty percent protection was conferred by, the zoster vaccine in the general population.
So good news for your patients who, have autoimmune disease and need that vaccine. A nice study looked at colored Doppler ultrasound in assessing, vascular changes in seventy nine patients with systemic sclerosis. They compared this to, normal nail hole capillaroscopy and other findings. They showed that abnormalities of colored Doppler ultrasound was associated in those who had high CRP levels, those who had a greater than twenty pack year smoking history, males, and those who had either digital pulp ulcers or digital pulp scars. This could become a useful tool in the assessment and management of patients with microvascular disease like that seen in scleroderma.
A small review of forty six patients, in India were taking methotrexate and develop pancytopenia. I think it's somewhat instructive. What they found in that population was that this did occur at a mean low dose of ten milligrams per kilogram I'm sorry, ten milligrams per week. But the main onset symptoms were that of severe mucositis and fever. And those that were at risk were those who had a low albumin, those who had renal failure, and more importantly, that amongst these, forty six patients, thirteen died.
So this is a highly, deadly event, that can be avoided by monitoring renal function and patients who are on the drug. A report from last week's AAOS meeting shows that smoking cessation prior to, a knee or hip arthroplasty actually improves outcomes. So those who are taking, who who are smoking prior to surgery actually had worse outcomes and more complications than those who actually had ceased. So, good instruction for your patients who are undergoing arthroplasty. A small but interesting report looked at, the rare occurrence of inflammatory bowel disease occurring in systemic juvenile arthritis patients, Still's disease patients, who and when it did was seen in this Israeli cohort of eighty one patients, the three cases that were seen, very low number, were all unified and that they were taking interleukin one inhibitors.
And, again, that's generally not a part of the spectrum of disease seen in Still's disease. I I I know adults very well, and I've seen many children with this, and IBD is not a common it's a very rare event. And the question that whether or not the associated with IL-one inhibition is even more quizzical. If you look at the data on IL-one and IBD suggest that maybe IL-one could be a useful therapy in patients with inflammatory bowel disease. So we'll look at the literature in the future and see if this crops up more, but I think it's an important report, especially for those of you who take care of patients with systemic JIA or adult onset Still's disease.
A systematic review of over 1,200 patients who were undergoing either hip or knee arthroplasty and were under the age of 55 showed that with a ten year follow-up, a very high degree of satisfaction and of eighty five percent or more and only about five percent revision rate suggesting that this may be a good population to do surgery. Again, it's always been suggested that patients who need hip and knee replacement should wait until the last possible moment or are much older. These new arthroplasties have always been said the last ten to fifteen years, but in fact, they're really built to last thirty years when properly managed, in the current, system, that we take care of patients. So again, trying to persuade your patients who are 55 to not have surgery may not be a good idea because there's a significant degree of success there. Again, the longevity of the implant would still be the issue and the study wasn't long enough to answer that question.
Rheumatic manifestations of the chikungunya virus was recently reviewed by Cassie Calabrese in a nice article that looks at the experience of infections followed in a French cohort in what's called the Rheumatochic study. That's right, Rheumatochic. Sounds like either an all female rheumatology faculty or some sort of new study group that won't let me in. Women are taking over rheumatology. Has always been an old white guy disease, but the new numbers on people going into rheumatology, the younger generation, it's going to be sixty percent female in the next decade.
I digress. This particular study actually looked at three zero seven patients and the cumulative experience that was seen there. Interestingly, the mean, number of joints seen at presentation was 6.5. So this is a polyarticular presentation that is symmetrical, and and over eighty percent of them have persistence of symptoms going out several years. So, again, this is gonna become a, I think, a larger, number in with time.
A lot of these mosquito borne infectious arthritities are cropping up in addition to the Zika virus. We have this now, the chikungunya, being added to also dengue. But then again, chikungunya and Zika are going to be a big issue in the future. What we really don't know is how to best treat them. Right now, they're getting the best anti inflammatory therapies that we usually would use for a symmetric chronic polyarthritis.
But the outcomes of that is right now not known. Last week, the New England Journal published a review article from, Chris Richland and Daphne Gladman and Robert Koller who, they have a really good article, you should take a look at it. It gives out the numbers that we all should know that thirty percent of patients with psoriasis will likely develop psoriatic arthritis. The prevalence numbers are somewhere between six and twenty five per ten thousand, at least in The United States. They review the comorbidity issue, the use of the Caspar criteria.
Dactylitis, is seen in half the patients. Erosions develop in half the patients within the first two years. They also talk about, the childhood onset of psoriatic arthritis where there's two types, the oligoarticular subset that is often has dactylitis and maybe ANA positive with a risk of uveitis, or the late onset group between ages six and 12 who have HLA B27 and a related enthesopathy, dactylitis, enthesitis, nail changes, some of them go on to develop one of the forms of spondyloarthritis or the undifferentiated form. A really nice review of the etiology and pathogenesis that's definitely worth the read. Found a nice article this week in the American Journal of Medical Sciences that reviews lupus hepatitis and leupoid hepatitis.
There's maybe some confusion between the two, but lupus hepatitis is the development of transaminitis and hepatitis in patients with lupus, whereas leupoid hepatitis was described in 1959, and is the same thing as, what we now call autoimmune hepatitis. They both are unified in the fact that they are associated with ANA positivity and hypergammaglobulinemia, and a response to need for immunosuppressive therapy and steroids, but they can be distinguished from each other. Up to half of patients will have some kind of liver abnormalities with their lupus and transaminitis is seen in a quarter of patients with lupus. On the other hand, autoimmune hepatitis, nearly a quarter of those patients meet criteria for lupus. So again, there can be some confusion.
In the review article, I think the main standouts, as far as distinguishing between the two could be that in lupus, you obviously develop low complements and anti ribosomal P antibodies, and you generally don't see that in autoimmune hepatitis or leupoid hepatitis. On the other hand, leupoid hepatitis, just like lupus, has a high degree of ANA positivity but has different autoantibodies including the, anti smooth muscle antibodies and the anti LKM antibodies. So a nice review, probably worth taking a look at. Also, a nice article from Len Calabrese and, doctor Bingham, in ARD and also featured on Medscape reviews a lot of the features that we see with the use of these new checkpoint inhibitors. These are drugs that target PD-one such as, pembrolizumab and nivolumab, and then CTLA-four, and that's ipilimumab.
These are used for skin cancer, melanoma, solid tumors. Again, very popular agents these days even being advertised on television, but they have been associated with autoimmune inflammatory phenomenon. Going to do a Bing keynote address at the SOTA meeting, the state of the art meeting the ACR is having coming up in April. You should look at that, we advertise that on our website. He's going to review these findings of what you see many autoimmune things, including thyroiditis and lymphoproliferative diseases and myasthenia gravis and hypophysitis, but the rheumatic disease manifestations include things like SWEET syndrome, Stevens Johnson, colitis, inflammatory arthritis, and sickest symptoms are really quite common.
So, you should also know that myositis and muscle involvement, even rhabdo has been reported. So, again, looking for these findings in patients taking these specific, chemotherapeutic drugs, should be, something to consider, going forward. Lastly, there's a nice new article about the Sjogren's Syndrome Foundation, and its new twenty seventeen treatment guidelines for Sjogren's Syndrome. This is an article published by Steve Parsons and a number of experts in the field. I have to applaud them for coming out with this.
It sort of puts on the map things for us to consider, especially when looking at the use of biologics in the management of disease, looking at the treatment of fatigue, and also looking at the treatment of inflammatory musculoskeletal pain. I think many of the guidelines they put forth, 19 recommendations specifically, are instructive, including saying that really there's no role for TNF inhibitors in the management of Sjogren's syndrome, that there might be a role of the use of rituximab in really difficult Sjogren's syndrome patients, such as those with cardioglobulinemia and vasculitis or vasculitis alone, severe parotid swelling, pulmonary disease or peripheral neuropathies and modern neuritis. But I think they're a little bit suspect, some of these guidelines, in my opinion, when it comes to, for instance, recommending rituximab for the use of xerostomia. Although the committee recommended it, there's very weak evidence to support it. Also, they also suggest that hydroxychloroquine may be useful in treating the fatigue of Sjogren's syndrome, again, citing weak evidence.
And then lastly, when talking about the treatment of inflammatory musculoskeletal pain, they go through the algorithm of using hydroxychloroquine first, then methotrexate, then both, and then if not that, using either leflinamide, sulfasalazine, azathioprine, or cyclosporine, all either moderate, which I find hard to believe, or weak evidence for those. So while I like the guidelines and I like the discussion that they'll create, I think there needs to be more discussion about this to know whether this is the way to go in managing your patients with Sjogren's. That's it for this week at roomnow.com. Be sure to go to the website to tune in for more news and information. Sign up, register, you'll get daily good information from us.
We'll give you Friday and I'm sorry, Saturday and Sunday off. But Monday through Friday, good news like this. You can go to the website and find the citations as well. That's it for this week. Enjoy your weekend.
Hi.
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