The RheumNow Week in Review - 5 January 2018 Save

It's 01/05/2018. This is the RheumNow we can review. I'm doctor Jack Cush, executive editor of rheumnow.com. And this week on RheumNow, the new year, a lot of good news. A nice teaching point was covered in a review article that shows that patients who are hospitalized and why they might get C diff infections could be due to some of the drugs that we use.

Certainly we know that antibiotics increase the risk of colonic colitis due to Clostridium difficile, but, I was not really aware that PPIs, H2 antagonist, Sucral fate, and then specific antibiotics, are associated with the higher risk, especially those PPIs and GI drugs. Carbapenems, cephalosporins, metronidazole, those are all I think fairly well known but it is PPIs. I had a patient recently who's had two or three consecutive hospitalizations for C. Difficile all resolved when she stopped her PPI therapy. An interesting study appeared in the literature talking about HBV testing.

This was comes from Dan Solomon and colleagues where they did claims data and they looked at hepatitis b testing and looked at testing specifically in RA patients who are about to start a DMARD. They did this both in The United States and also in Taiwan and they showed that the rate of hepatitis b testing in both The United States, twenty percent, and in Taiwan, twenty five percent was really quite low and unexpectedly low. And this is for all course for all DMARDs. Certainly should be a high priority for methotrexate and Arava, but really should be done, I think, in all patients going on DMARDs because at some point, they're gonna be on some drug, either a biologic or a TNF that will need this. Specifically, they also showed that The US was a little bit more likely to use more than one hepatitis test as opposed to just one.

That was forty three versus sixteen percent comparing The United States to Taiwan. So, again, the rule here is that you must do testing and you must do more than one test. The test that that I recommend is a hepatitis b surface antigen, a hepatitis b core antibody, a hepatitis b surface antibody, and a hepatitis c antibody test. The b surface antigen means active infection. Nobody should get a bad drug, a hepatotoxic drug, or a biologic.

The core antibody, if positive, means that they have resolved infection when the surface antigen is negative. And that means they may proceed presuming they're not immunosuppressed. The surface antibody tells you that they're immunized or not, and that may be important in going forward. An interesting study comes from Corona this year looking at patients who started either abatacept or a TNF inhibitor and looked at the influence of CCP positivity on either response. What they did show was that being CCP positive did not affect whether or not someone responded well to a TNF inhibitor.

However, if you were CCP positive, you were far more likely to respond to abatacept suggesting there's something unique about CCP positivity in patients who receive abatacept and rituximab and a few drugs. Other drugs it doesn't seem to be a big issue. This I think is an useful biomarker when practicing medicine and prescribing the right next therapy. Updated studies about chikungunya, a nice cohort study of their experience in Colombia, looked at a hundred and three patients and found that, thirty three of the seropositive, patients, also had the virus in in the synovial fluid and that twenty, that almost between twenty five and roughly thirty percent of patients had chronic arthritis lasting out to as much as twenty two months. So there seems to be, a cohort of patient patients affected with this virus who may chronic arthritis that looks a lot like rheumatoid arthritis.

When tested twenty two months later, they had five tender joints, a mean of three or three and a half swollen joints, and they often need to be treated as if someone who has a a serum negative inflammatory polyarthritis. I threw in a good New Year's tip for both patients and doctors. Medication safety tip number one, patients should an updated medication list and either bring the medication list or their all their medicines to every visit. Otherwise, we the prescribers are guessing and that's not good for patients. Number two, bring the med list to all doctor visits, bring the drugs to all doctor visits.

Number three, fill the same prescription medicine at the same pharmacy prescribed by the same doctor. If you start mixing it up from the patient's side that it's half are filled over there, half are filled over here, That's prescription for both errors, polypharmacy, and increased safety risk. Number four, take the drug as ordered as prescribed as it says on the label. One of the biggest mistakes that patients make is taking less medicine. They think might be safer.

In fact, taking less medicine is not safer. Taking less medicine is riskier and may expose you to higher risk, more disease activity, and therefore more problems. Take as ordered. Number five, when a prescriber, prescribes a drug, he should be asked to discontinue a drug. Otherwise, physicians become the vectors of polypharmacy which is a gigantic public health problem.

You may wanna look on the website and find this, link to a Ted video on the biology of knuckle cracking and why it feels good. This comes from a great rheumatologist in The UK, Eileen Tan, who, likes to tweet a lot of interesting stuff. She's interested in osteoarthritis. She's a runner. She's a health fiend.

She's really a smart gal, and she found this great video which is a really nice explanation as to why your knuckles crack when you do those things you do. And yes, it's not a bad thing, it's probably a good thing. What about the use of biologics in, patients with spondylo arthritis. An interesting study, the ASAS ComoSpA study looks at, 22 countries, 3,370 patients, and looks at the uptake of either conventional DMARDs or biologic DMARDs in a sort of cross sectional analysis. In this cohort, they found thirty eight percent or twelve seventy five people who were treated with a biologic and this was however, the point of the study was it varied widely being very low in some companies like China where it was five percent and very high in other companies like Belgium where it was seventy four percent.

Behind Belgium were not surprisingly France, Colombia, and The United States. Colombia, I was a bit surprised at. A lot of the literature this week about autologous stem cell transplantation and its use in scleroderma. A single center study, from Northwestern, I believe, looked at 18 patients who received autologous autologous stem cells, and and looked at the profile and and basically showed that that, it was not only effective but generally safe. These are high risk patients with bad disease.

They did have four deaths, and their takeaway message of their single report was that there's a very strong need to select the right patients to reduce the toxicity when doing this therapy. Therapy. Quite interestingly, yesterday, the New England Journal published the results of the Scott trial and you remember the Scott trial was reviewed at the last ACR meeting. Was a sort of the big deal. This was a trial of 75 patients from 26 centers between 2005 and 2011.

They were randomized to receive either stem a cell therapy or not. Their stem cell therapy included myeloablation with total body irradiation and then reconstitution with a c d, 34 positive auto autograft cells versus just receiving infusions of cyclophosphamide seven hundred fifty, milligrams per meter squared for up to four years. When you looked at the data, it looked like there needed to be at least two years to see the differences between the groups, which is a little bit disconcerting, but that there were differences out at forty eight months with sixty eight percent of the patients receiving stem cell transplant responding to a multi modal response definition and that was superior to the thirty two percent seen in those receiving cyclophosphamide. So I think that's an important study that may change the way, we treat scleroderma certainly gives a lot of hope to patients who have severe advancing systemic sclerosis. Also this week, interesting studies, two interesting reports in the Annals of Internal Medicine.

One, a meta analysis, by, Maria Suarez Almazar and her colleagues, another being the editorial to that report. And specifically, looks at the issue of autoimmunity and the use of these immune checkpoint inhibitors. As you know, these are new great advances in cancer chemotherapy. And and doctor Calabrese goes on to explain that, again, these immune checkpoints exist in all of us in a way to sort of put the brakes on when the immune system gets over activated. And what has happened here here is that now this is being therapeutically manipulated with these checkpoint inhibitors where you basically get rid of or diminish those breaks to reinvigorate an exhausted immune response in the case of cancer.

The problem is by reinvigorating these these mechanisms, you may bring about what has been seen as these immune, mediated adverse events. As you know, there's a lot of autoimmune and inflammatory disorders that can result. There are hundreds of patients that are out there. Their common manifestations include things like RA, psoriasis, psoriatic arthritis, etcetera, and they may be difficult to treat. What is interesting here is that when these drugs are being developed, patients who had autoimmune diseases were excluded.

And so what, Suarez Almazar and colleagues did was they searched the literature, they found 49 publications in one hundred and twenty three patients who, were had 30 different, autoimmune or, inflammatory disorders who went on to receive these immune checkpoint inhibitors. And what they found interestingly was seventy five percent of them developed these immune related adverse events that were, like those seen in people without autoimmune disease. And what we do know about these is that they often require, steroid therapy and or, biologic therapy to control their disease. They can be difficult to control. This still remains an area of great interest and and how to manage them is going to be challenging going forward.

I had a report along with Jeff Curtis in Journal of Rheumatology this week that you can see, that talks about the use of, serving rheumatologists to find out about how they use metrics in their practice and whether or not they practice treat to target therapy. We surveyed nearly 1,900 US rheumatologists and had 439 respond to our 2014 survey. We compared that to the results seen in 2005 and 2009. And we found that basically, at current time, fifty eight percent of rheumatologists admit to doing some formal measure of disease activity or metric in the care of rheumatoid arthritis. We have seen that there's been a significant growth from 2005 and 2008 to the current time in the use of these, but despite that growth, you know, almost half are still not doing this.

The measures that are most commonly being used in 2015 was the HAC score, any version of the health assessment questionnaire in thirty six percent of people. Twenty seven percent of US rheumatologists do the rapid three making it the most common and making it almost double, not quite double that of the CDI or the the clinical disease activity index of Smolin and Alitaha. And dash 28 is being done by fifteen point seven percent. Very few are doing esoteric things like the gas score, which is what I advocate for in my practice, but the Vectra MBDA, a biomarker of these activity is being done by twelve point eight percent of rheumatologists. The the study went on also to show that if you provide information in varying amounts and the more metrics you provide, do people in fact give more change their therapy?

Well, they do are more likely to give more drugs with more information but it does not appear from that data to show that they in fact practice a treat to target approach in the care of RA. So again, metrics and their role in practice remains to be Lastly, there's an interesting report that mirrors some of the data seen at the last ACR meeting in 2017 and that is that bone marrow edema can be found not just in people with inflammatory disorders but it's also found in normals, athletes, and military recruits. At the ACR, there were two such abstracts making the same point. This particular abstract in the literature looks at 22 military recruits who had, MRI of their SI joints and went through six weeks of vigorous military recruit training and then had a repeat MRI of their SI joints. They found that before they began training, forty percent had evidence of SI joint bone marrow edema, that's forty one percent in fact, and this did increase to by nine percent to fifty percent after six weeks.

This is not a significant increase. And the same kind of minor change, nonsignificant change was seen for those meeting the ASAS definition of sacro itis. So, this basically says that that these bone marrow, findings that might suggest underlying damage and or inflammation may be seen in normals. They can be seen in hockey players and athletes, and they may not be indicative or specific for inflammatory disease. There are measures that do make them specific including the depth of them, the severity of them, the placement of them.

But by and large, just by itself, marrow edema is not a specific finding for inflammatory disease. That's it on RheumNow this week. You can go to the website and find these citations and learn more about these particular reports. You can subscribe to our reports on YouTube, on iTunes, and new, in addition to SoundHound, we're now on Stitcher. You can if you like Stitcher and you listen to podcasts on Stitcher on your Android phone or any phone, you can subscribe to the room now.

We can review podcasts on Stitcher. That's it. Have a good week. Have a happy New Year.