RheumNow Week In Review Four Fingers Are Best %2810.12.18%29 Save
RheumNow Week In Review Four Fingers Are Best %2810.12.18%29 by Dr. Cush
Transcription
It's 10/12/2018. This is the Room Now we can review. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. You can follow us on these video casts or on our podcast, which are available on a number of different channels, including iTunes, SoundCloud, Stitcher, Spotify, TuneIn, Android Auto, Apple Car Talk, and and we have a new blog called RheumNow blogs that you can listen to on all of those and also on Alexa.
Alexa, play RheumNow blogs. Try it out. Let me know how it comes out. This week in the news, the renal effects of allopurinol, should you worry? Overlap patients, are they better off, worse off, or are they just different?
Do you know what happens when your lupus patients go to the emergency department, the ED? Do you know what happens to the frequent flyers? You should probably worry. At the top of the news is today, October 1238, is World Arthritis Day. EULAR has designated this day as World Arthritis Day.
They have a campaign on their website. You can find the link on, our website or go to EULAR and you can look about, look at the awareness they're trying to create amongst, the community, amongst patients, researchers, and clinicians like yourself. Spread the word, it's World Arthritis Day. People should do more, learn more, know more, and tune into RheumNow more. There's an interesting study about lupus patients when they go to the emergency room.
This is a study of patients who are frequent flyers, they call persistent users, seventy seven of them, versus fifty two who were limited users of emergency department services. When you compare the encounters, there was a big difference, eleven forty three versus three thirty five. And it turns out that again, persistent users were more likely to go to the emergency room because of pain thirty two percent of the time compared to limited users only eighteen percent of the time. Turns out that persistent users were more likely to be African American on Medicare, on dialysis or have nephritis, and beyond long term opioid therapy. When you look at those who were going to the emergency room just for pain reasons, the persistent users were more likely to be obese, have fewer comorbidities, and also again, long term opioid therapy.
Do your lupus patients use opioids? They really shouldn't unless they have AVN or an acute painful process like a fracture or a fall. But there I think are a surprising number of our lupus patients who are on opioids and maybe that's something to worry about. I look at my patients across the board, who are the ones who get most of the opioids? You know, back pain patients, patients who had chronic pain for multiple reasons, in the past, not so much fibromyalgia, secondary fibromyalgia tend to be the few who get opioids.
And I must say, I think I have a few patients with lupus who are on opioids and I often wonder why we're on that and something to look at. How about the contact study? You're aware about this? This is actually a new study that was reported at a recent British Society of Rheumatology meeting. Three ninety nine acute gout patients who were treated with either colchicine or naproxen.
The contact study. It's an open label study, so that's a weakness of this. And they really looked at basically equivalent doses of naproxen versus colchicine in treating acute gout. And guess what? Naproxen was not inferior to colchicine or vice versa.
But there was a trend favoring naproxen as far as earlier relief of pain or relief of pain in the earliest moments of acute gout. They had lower pain scores, they had fewer side effects, they used less rescue pain medicine. These were trends and not significant differences. But again, I don't use colchicine. I stopped using colchicine, what, eight years ago when colchicine went from being 5ยข a pill to $5 a pill, and I have not needed it to manage acute gout.
I use very, very little colchicine even though it's now generic. Most of my acute gout is managed with either naproxen or corticosteroids. This data sort of supports that positioning. So there's another study that comes from another Congress, in this case, the International Congress on Spondyloarthritis. The recent 2018 conference specifically looked at women with spondylitis.
The overall study of three fifty nine AS patients followed for nearly five years found that women were less likely to respond to biologic therapy. They're also less likely to be adherent to therapy. They had worse pain scores, worse ASTAT scores. And again, compared to men, women have a different quality, quantity and presentation of disease when it comes to ankylosing spondylitis and spondyloarthritis. Think this merits, further investigation and maybe further different approaches to one, earlier identification, two, maybe better therapy for women.
I don't know if you're aware, but NAFTA has been resurrected in a new bill, now called USMCA, The US Mexico Canada Agreement that was just signed by the Trump administration this past October 2 or October 3. A lot of things in there about North American free trade and a lot of changes that obviously is going to be beneficial to all three countries. But you may not be aware that there's a provision in there about biologic protection. You know, United States was twelve years for biologic protection and there's been talk during the Obama administration of cutting that back to seven years to promote cheaper drugs and wider access to therapy. Now, this is a sort of win for the makers of the biologics and not the biosimilars because there's a guaranteed protection of at least ten years in The United States and it's gonna be about eight years in Canada and five years in Mexico.
So again, the NAFTA remake called USMCA has some benefits to the makers of biologics. Not a news item, but I tweeted it this week because I thought it was important just to remind everybody that we should be promoting influenza vaccination. This is the time to get it. September, October is when it's available. The earlier you get it, the better off your patients are going to be.
A lot of our patients do need influenza vaccination. I think you should know that the new rules are out there about methotrexate use. We reminded people hold methotrexate for two weeks after influenza is given, the vaccination is given. And that's because of research presented at the last ACR meeting, the plenary session showing that the best way to give the influenza vaccine is to give it, hold methotrexate for two weeks and then resume it. Your patients won't flare, it allows for optimal immunogenicity by the vaccine, and is it sort of a win win across the board?
The data, the research is out there we previously reported on this, you could look it up about methotrexate and vaccination if you want to find the citation. An interesting study comes, looking at nail fold capillaroscopy. A nice study done by experts in the field, studied 173 patients, over 1,600 images, and they looked at the sensitivity of finding features of scleroderma like disease. And basically they said that the best results were seen when you examine all eight fingers, not the thumbs. The sensitivity was 75%.
If you just do four fingers, that's actually two fingers on both hands. The ring finger and the middle finger, those two, I mean this as well as I can, 67%. Two ring fingers, that's 60%. And one finger, 32 to 70 to to 47% sensitivity. So the bottom line is the more fingers you do, the better off you're going to do.
The best fingers to do if you're gonna do any are gonna be these two fingers here, the middle finger and the ring finger for the best objectivity. Obviously, use oil or gel and have a device that will do that. It doesn't have to be an expensive device, we've talked about that here, in the past. An interesting study comes out from Journal of Rheumatology on scleroderma overlap. And the question is, are they different?
Amongst a large clinic of twelve fifty two, SSE patients, they found sixty six patients who have an overlap with lupus. They call them SSE SLE patients. Thus the prevalence of this group is, six point eight percent. Are these patients different? What they did find that was important was a much higher rate of pulmonary hypertension, fifty two percent versus thirty one percent in scleroderma SSC only patients.
At the same time, they had less classic features of scleroderma, including less calcinosis, less telangiectasia, and less diffuse skin thickening that would be seen with SSC. So again, they are different, and they tend to have the same both groups, the SSC only and the overlap patients tend to have the same rates of renal crisis and ILD and other things that you worry about with scleroderma, which therefore everybody should be monitored and treated for such things. But primary, pulmonary arterial hypertension is something that is unique to this group. A nice study looks at allopurinol use in, allopurinol initiators who have acute, who have actually gout, chronic gout. They looked at, four thousand seven hundred and sixty patients initiating allopurinol at a dose of three hundred milligrams a day or higher, and they compared it to the same number who did not initiate allopurinol and they followed them for a five year period and looked specifically at the development of stage three CKD or chronic renal disease.
Overall, stage three CKD was lower in allopurinol users, eleven point one percent versus thirteen percent in those who did not initiate allopurinol, suggesting that allopurinol use is renal protective to the tune of about thirteen percent. And those were those results were significant. Our last report is about carpal tunnel syndrome, World Arthritis Day, World Arthritis Week. MMWR features a report from California that looks at the risk of developing carpal tunnel syndrome, and they found that the rate was six point three per ten thousand full time workers. Higher in women, higher in industries that manufacture apparel, do food processing, and perform administrative work.
More specifically, as they said, jobs that will get this textile, fabric finishing, coating mills, apparel accessories, apparel manufacturing, animal slaughtering, animal processing, telephone operators, cafeteria workers, food concession workers, coffee shop and counter workers, and electrical workers or electromechanical assemblers. So we certainly see a lot of carpal tunnel syndrome in our case in rheumatology because of the association with inflammatory arthritis and arthritis in general. But obviously it can happen in people who don't have arthritis. And I think that we should be aware of it in these populations. That's it for this week at roomnow.com.
Go to the site to click on these links to learn more about these news items and journal reports. Be sure to come by the RheumNow booth at ACR. We have a lot of exciting new things going on and expanded faculty. A lot of news reports will happen from the booth. We're going to have the RheumNow roundtable with experts discussing topics related to rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout and osteoporosis.
I think it's going to be exciting. We'll see you at ACR. Bye now.
Alexa, play RheumNow blogs. Try it out. Let me know how it comes out. This week in the news, the renal effects of allopurinol, should you worry? Overlap patients, are they better off, worse off, or are they just different?
Do you know what happens when your lupus patients go to the emergency department, the ED? Do you know what happens to the frequent flyers? You should probably worry. At the top of the news is today, October 1238, is World Arthritis Day. EULAR has designated this day as World Arthritis Day.
They have a campaign on their website. You can find the link on, our website or go to EULAR and you can look about, look at the awareness they're trying to create amongst, the community, amongst patients, researchers, and clinicians like yourself. Spread the word, it's World Arthritis Day. People should do more, learn more, know more, and tune into RheumNow more. There's an interesting study about lupus patients when they go to the emergency room.
This is a study of patients who are frequent flyers, they call persistent users, seventy seven of them, versus fifty two who were limited users of emergency department services. When you compare the encounters, there was a big difference, eleven forty three versus three thirty five. And it turns out that again, persistent users were more likely to go to the emergency room because of pain thirty two percent of the time compared to limited users only eighteen percent of the time. Turns out that persistent users were more likely to be African American on Medicare, on dialysis or have nephritis, and beyond long term opioid therapy. When you look at those who were going to the emergency room just for pain reasons, the persistent users were more likely to be obese, have fewer comorbidities, and also again, long term opioid therapy.
Do your lupus patients use opioids? They really shouldn't unless they have AVN or an acute painful process like a fracture or a fall. But there I think are a surprising number of our lupus patients who are on opioids and maybe that's something to worry about. I look at my patients across the board, who are the ones who get most of the opioids? You know, back pain patients, patients who had chronic pain for multiple reasons, in the past, not so much fibromyalgia, secondary fibromyalgia tend to be the few who get opioids.
And I must say, I think I have a few patients with lupus who are on opioids and I often wonder why we're on that and something to look at. How about the contact study? You're aware about this? This is actually a new study that was reported at a recent British Society of Rheumatology meeting. Three ninety nine acute gout patients who were treated with either colchicine or naproxen.
The contact study. It's an open label study, so that's a weakness of this. And they really looked at basically equivalent doses of naproxen versus colchicine in treating acute gout. And guess what? Naproxen was not inferior to colchicine or vice versa.
But there was a trend favoring naproxen as far as earlier relief of pain or relief of pain in the earliest moments of acute gout. They had lower pain scores, they had fewer side effects, they used less rescue pain medicine. These were trends and not significant differences. But again, I don't use colchicine. I stopped using colchicine, what, eight years ago when colchicine went from being 5ยข a pill to $5 a pill, and I have not needed it to manage acute gout.
I use very, very little colchicine even though it's now generic. Most of my acute gout is managed with either naproxen or corticosteroids. This data sort of supports that positioning. So there's another study that comes from another Congress, in this case, the International Congress on Spondyloarthritis. The recent 2018 conference specifically looked at women with spondylitis.
The overall study of three fifty nine AS patients followed for nearly five years found that women were less likely to respond to biologic therapy. They're also less likely to be adherent to therapy. They had worse pain scores, worse ASTAT scores. And again, compared to men, women have a different quality, quantity and presentation of disease when it comes to ankylosing spondylitis and spondyloarthritis. Think this merits, further investigation and maybe further different approaches to one, earlier identification, two, maybe better therapy for women.
I don't know if you're aware, but NAFTA has been resurrected in a new bill, now called USMCA, The US Mexico Canada Agreement that was just signed by the Trump administration this past October 2 or October 3. A lot of things in there about North American free trade and a lot of changes that obviously is going to be beneficial to all three countries. But you may not be aware that there's a provision in there about biologic protection. You know, United States was twelve years for biologic protection and there's been talk during the Obama administration of cutting that back to seven years to promote cheaper drugs and wider access to therapy. Now, this is a sort of win for the makers of the biologics and not the biosimilars because there's a guaranteed protection of at least ten years in The United States and it's gonna be about eight years in Canada and five years in Mexico.
So again, the NAFTA remake called USMCA has some benefits to the makers of biologics. Not a news item, but I tweeted it this week because I thought it was important just to remind everybody that we should be promoting influenza vaccination. This is the time to get it. September, October is when it's available. The earlier you get it, the better off your patients are going to be.
A lot of our patients do need influenza vaccination. I think you should know that the new rules are out there about methotrexate use. We reminded people hold methotrexate for two weeks after influenza is given, the vaccination is given. And that's because of research presented at the last ACR meeting, the plenary session showing that the best way to give the influenza vaccine is to give it, hold methotrexate for two weeks and then resume it. Your patients won't flare, it allows for optimal immunogenicity by the vaccine, and is it sort of a win win across the board?
The data, the research is out there we previously reported on this, you could look it up about methotrexate and vaccination if you want to find the citation. An interesting study comes, looking at nail fold capillaroscopy. A nice study done by experts in the field, studied 173 patients, over 1,600 images, and they looked at the sensitivity of finding features of scleroderma like disease. And basically they said that the best results were seen when you examine all eight fingers, not the thumbs. The sensitivity was 75%.
If you just do four fingers, that's actually two fingers on both hands. The ring finger and the middle finger, those two, I mean this as well as I can, 67%. Two ring fingers, that's 60%. And one finger, 32 to 70 to to 47% sensitivity. So the bottom line is the more fingers you do, the better off you're going to do.
The best fingers to do if you're gonna do any are gonna be these two fingers here, the middle finger and the ring finger for the best objectivity. Obviously, use oil or gel and have a device that will do that. It doesn't have to be an expensive device, we've talked about that here, in the past. An interesting study comes out from Journal of Rheumatology on scleroderma overlap. And the question is, are they different?
Amongst a large clinic of twelve fifty two, SSE patients, they found sixty six patients who have an overlap with lupus. They call them SSE SLE patients. Thus the prevalence of this group is, six point eight percent. Are these patients different? What they did find that was important was a much higher rate of pulmonary hypertension, fifty two percent versus thirty one percent in scleroderma SSC only patients.
At the same time, they had less classic features of scleroderma, including less calcinosis, less telangiectasia, and less diffuse skin thickening that would be seen with SSC. So again, they are different, and they tend to have the same both groups, the SSC only and the overlap patients tend to have the same rates of renal crisis and ILD and other things that you worry about with scleroderma, which therefore everybody should be monitored and treated for such things. But primary, pulmonary arterial hypertension is something that is unique to this group. A nice study looks at allopurinol use in, allopurinol initiators who have acute, who have actually gout, chronic gout. They looked at, four thousand seven hundred and sixty patients initiating allopurinol at a dose of three hundred milligrams a day or higher, and they compared it to the same number who did not initiate allopurinol and they followed them for a five year period and looked specifically at the development of stage three CKD or chronic renal disease.
Overall, stage three CKD was lower in allopurinol users, eleven point one percent versus thirteen percent in those who did not initiate allopurinol, suggesting that allopurinol use is renal protective to the tune of about thirteen percent. And those were those results were significant. Our last report is about carpal tunnel syndrome, World Arthritis Day, World Arthritis Week. MMWR features a report from California that looks at the risk of developing carpal tunnel syndrome, and they found that the rate was six point three per ten thousand full time workers. Higher in women, higher in industries that manufacture apparel, do food processing, and perform administrative work.
More specifically, as they said, jobs that will get this textile, fabric finishing, coating mills, apparel accessories, apparel manufacturing, animal slaughtering, animal processing, telephone operators, cafeteria workers, food concession workers, coffee shop and counter workers, and electrical workers or electromechanical assemblers. So we certainly see a lot of carpal tunnel syndrome in our case in rheumatology because of the association with inflammatory arthritis and arthritis in general. But obviously it can happen in people who don't have arthritis. And I think that we should be aware of it in these populations. That's it for this week at roomnow.com.
Go to the site to click on these links to learn more about these news items and journal reports. Be sure to come by the RheumNow booth at ACR. We have a lot of exciting new things going on and expanded faculty. A lot of news reports will happen from the booth. We're going to have the RheumNow roundtable with experts discussing topics related to rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout and osteoporosis.
I think it's going to be exciting. We'll see you at ACR. Bye now.
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