The RheumNow Week In Review EULAR18 Epilogue %286.22.18%29 Save

It's the 06/21/2018. This is the RheumNow week in review. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. This week, we have some post Ullar thoughts.

We have a $30,000 price tag on a Pet Rock. And I have a solid answer to the age old question, doctor, could this all be due to stress? But first, I wanna say something to the kids in the room or in the car. Kids, Josh, Diane, Bianca, whatever your name is, you gotta calm down. You gotta be quiet.

Mom needs to listen to this podcast. I know you'll have to listen to me, doctor Jack Cush, da da da da da every week, but this is kind of important to mom and dad. So get out your iPads, get out your Rubik's cube, ask your mom what that is, and just calm down for about twelve, fifteen minutes and let them do this. They're gonna do it every Saturday morning anyway. Now back to the podcast.

As you know, we just got back from EULAR. It was a very interesting meeting. It was in a great town of Amsterdam. I would say a few things. Number one, if you didn't go and wanna know something about the meeting, the easy way would be to go to podcast@roomnow.com.

We have ones from day one and two, three and four. You can look at it on or listen to it on iTunes, Stitcher, SoundCloud, wherever you get podcasts. It's an easy way to hear from a lot of good people on some interesting subjects. I think you'll find interesting. Second, the bicycles in Amsterdam were unbelievable.

I was warned ahead of time that it is one biking town. They're all over the place and pedestrians are at risk because they own the bike lanes and there's bike lanes everywhere. So yes, I had to look twice, three times before I crossed the road because they were zipping by in the dozens and in packs all morning, all night, all day. It was impressive. Stems back from the seventies and eighties when there were a lot of car accidents and deaths.

There was the high price of gasoline. Bikes took over, and they've been dominant force in Amsterdam. It's part of the culture, part of the what makes them interesting and unique. But everybody was talking about the bikes. It's a wonderful thing.

It was a little bit of a dangerous thing, but nonetheless, they were all over the place. A word to you, LAR. You need more cities like Amsterdam. Amsterdam was fabulous. Everybody really enjoyed it.

They enjoyed the meeting, but they really enjoyed the city. There was plenty to do. Tons of canals, great walk city, easy to get on and off. I was told to get on the hop on, hop off. I was looking for a bus.

It wasn't the bus. It was actually the canal tours that you could go on and off all around the city. Pretty impressive. As far as the meeting, think that you'll find, if you looked at the data, there was a lot of data on therapeutic weaning, which I still find interesting, that we're doing studies about the ability to wean when the ACR has pretty clear guidelines that if you're in remission, don't change anything. Actually, you're in low disease activity state, don't change anything.

But if you're in remission, you could space out therapy or take off one of two drugs, preferably the DMARD as opposed to the biologic, you could go either way. But if you're gonna do weaning studies, why not do studies that look at either x-ray outcomes or financial outcomes? Showing me that you can do it or not do it and FLAIR or not FLAIR is really not that helpful anymore. But yet we still see in the last two or three years, a lot of these studies, I don't know that they're adding to our, our fund of knowledge on this. So this week's report, a meta analysis on, how to treat osteoarthritis.

You know, you and I struggle in treating osteoarthritis, especially inflammatory type and there's a lot of disappointing data, a lot of disappointing experience on how to treat osteoarthritis and inflammatory osteoarthritis. This specific meta analysis looked at the use of DMARR therapy or biologic therapy in people with osteoarthritis and showed, guess what? Nope. Across the board, no better than placebo. So still, it's analgesics, it's lifestyle, it's contraptions.

You know, inflammatory osteoarthritis is my favorite regimen. Tape up fingers that are bothering you, low dose prednisone two point five, two milligrams a day along with acetaminophen six fifty taking up to three grams, four grams a day even. Those people do very, very well, better than anything else. If you got another idea, do a study, improve it. Anchor associated vasculitis, a lot of the meeting about ANCA associated vasculitis, you might want to look at Lenny Calabrese's interesting report on that.

He chaired the sessions on vasculitis. But specifically, this cohort of two fifty patients looked at the risk of serious infection, especially during the induction period. They found that a third of their patients have serious infections. That's gigantic. It's not surprising though given that most patients at the induction phase get hydrosteroids and they're also on immunosuppressive like azathioprine, mycophenolate, maybe even cytotoxin, etcetera.

So one third get SIEs, serious infection events, hospitalizeable infections. Risk factors are age, smoking, creatinine being very high, greater than 5.7, CD four T cell counts less than two eighty one, and being on IV cyclophosphamide. An interesting study looked at a cohort of JIA patients, a 113 patients, and specifically looked at the ability to find a cult IBD using a camera study. I thought it was interesting. And they did find a very small percentage, but it was seven out of a hundred, about six percent who did have occult asymptomatic but clear cut IBD that was confirmed on colonoscopy.

I like this sort of technology could be used in your spondylitis patients. It could be used in patients who are having bowel problems, maybe related to IL-seventeen inhibition, but it's a nice tool that should be considered more. An interesting study comes from Singh in Cleveland, who looked at a very large claims data set on gout patients, elderly gout patients who, were followed over a long period of time and showed not surprisingly they're at higher risk for myocardial infarction. Their rate was twofold higher than patients in the claims data set who did not have gout. And again, this is something that we need to be, cognizant of.

Gout needs to be treated aggressively. This is another one of those parameters where A, I think inflammation contributes to the risk of cardiovascular disease. Also, the hyperuricemia, and its contributions or its co associations with the metabolic syndrome also as this risk, both of which strongly call for an aggressive treat to target strategy in gout. Speaking of pet rocks, if I told you that the price of a pet rock, which cost you a buck $2.80 back in the seventies, look it up if you're born after the seventies, Now costs $30,000 to be shocked, outraged, whatever. Well, guess what?

One of the most expensive drugs on the market right now is penicillamine, specifically the trade drug cupramine. The price on it is $31,000 a year or almost $300 a pill. It's indication, the rare, rare, rare disease, Wilson's disease. It's a 50 year old plus drug. It's got tons of side effects.

Again, I think Congress needs to step up and do something about outrageous drug pricing. This is one such example. There's an interesting report that, just appeared in the OB literature about the use of nonsteroidals and the risk of miscarriage. We certainly know nonsteroidals can't be used in the late stages of pregnancy because of what it'll do to the ductus arteriosus. We also know that, many patients with arthritis, this is one of the most common drugs that will be maintained during the period in which the patient is trying to conceive and throughout many of the, first few months, if not the entire pregnancy up until week thirty two.

But the question is whether or not prostaglandins, and their inhibition may have something to do with what happens at implantation. This specific study looked at a very large cohort of women, over a thousand who were, followed. Many of them had exposure to drugs and they divided the patients into three different groups. Those exposed to nonsteroidals, those who are exposed to acetaminophen, those who had exposure to neither. And specifically they showed that being on a nonsteroidal gave you a fifty nine percent increased risk of miscarriage compared to those not exposed and compared to those on acetaminophen, a forty six or forty five percent increased risk.

The risk was greatest for early miscarriages, meaning less than eight weeks of gestational age, and there was a fourfold increased risk. The other people who are at risk here were women who had very low BMI's, seem to be also more at risk. So again, it sort of, speaks to some of the advice you might need to give your patients who are making, planful decisions about trying to get pregnant. Not steroids may not be your mainstay drug in such a population. What about stress?

You know, a number of years ago, I made up forms that you could use to screen patients with. And one such form you could find on RheumNow, it's a screening form. I used to have on there for both new patients and follow-up patients. I used to have on there a question, what is your stress level? And you know what?

I took it off because everybody wrote high. Didn't matter whether you were a kindergarten teacher, whether you were someone who was retired and in a hammock all day long, whether you, you know, proofread for the news. It didn't matter. Everybody perceives themselves as being under incredible stress. And we always get that question, could this have been due to stress?

How did this happen to me? Yes, it's probably good to evoke stress, but everybody's got stress. Well, this very interesting study looked at one hundred thousand plus patients who have true stress related disorders like PTSD, and then compared them. These are diagnosed individuals and followed them for like ten years and compared them to people who did not have any exposure to stress, almost a million people, and compared them to about a 100,000 siblings, siblings of those who were stressed, who themselves didn't claim to be stressed. The interesting data was that over ten years, the risk of an autoimmune disease in someone with a stress disorder like PTSD was nine point one per one thousand patient years, but in the other two groups, sibling group and the non stress group, was only six per one thousand patient years.

So there's a two and a half to threefold increased risk of autoimmune disease when you're exposed to stress. Who's at higher risk? The younger patients, and those are on SSRI for PTSD. Now is this real or is this fishing for a p value? I think it's real enough that I can now say yes.

Stress is one of the factors and, yes, you should do all you can to control it. That's another study. Lastly, I'm gonna get into seronegative and seropositive RA. I was asked to write an editorial, on seronegative RA and I've been mulling this one over for a long time. I think it's a big challenge.

I think there's a lot that we don't know about seronegative RA. We certainly know that there's a subset of those people early on who'll go into remission, there's a subset of those people after many years who will declare that they have some other disease like occult IBD or an occult SPA, spondyloarthritis. But there is a lot of data that speaks to two seronegative disease. This one report I have looked at about two fifty patients, two hundred were seropositive, two hundred were seronegative, and then follow them on their response to nonsteroidals and whatnot. At baseline, turns out that seronegative patients tend to have more disease and more severe disease than do seropositives.

Most people think quite the opposite, but it turns out that you need more and it's more swollen joints, more tender joints, higher dash 28 values. And that's because you probably need more joints to achieve an ACR ULA definition of of of having the disease RA. Turns out that over time, that many of them will do very well. Some will actually go into remission. But when these people were followed on conventional DMARC therapy after a year, the seronegatives may have responded better, but by two years there was no differences in response.

So they are different at the outset, their behavior may be different. I think there's a lot to be learned about seronegatives versus seropositive as we go forward. That's it for this week at roomnow.com. Make sure you go to the website to find these links to learn more about what's hot in rheumatology. Note that next week, Monday, I think you'll be seeing a new feature on our website and in our email called therapeutic update.

These will be a matrix of videos around a specific topic. This case, it's going to be around UR two thousand eighteen with a collection of what I think are my favorite and most popular videos from that meeting. Take a look at it. I think you'll like it. That's we that's it for this week.

See you next. Bye.