The RheumNow Week In Review Handshakes Or Hugs %288.3.18%29 Save

It's the 08/03/2018. This is the RheumNow we can review. Hi, I'm Doctor. Jack Cush, executive editor of roomnow.com. This week, the consequences of gout when it gets hospitalized.

What is the true risk of psoriatic arthritis in patients with psoriasis? And if you're a mother who has rheumatoid arthritis, do you confer some risk to your offspring? What if it wasn't just rheumatoid arthritis? This week, we have a lot of news, but before that, I wanna give you, some information about two important lectures coming up on August 11. That's next week.

It's gonna be Capital City Rheumatology Review in Washington, DC. This is being run by arthros.org, which I'm a part of. That'll be hosted by Sergio Schwartzman with a fabulous faculty. The week following, I'll be running the meeting in Nashville, the Music City Rheumatology Review on August 18. Both of these have stellar faculties, free programs, free registrations, a CME course.

If you're a fellow when you're traveling to the meeting, can pay for your hotel night. So go register and then email us and they'll pay for your hotel room. If you're a fellow, you gotta be a fellow to do this. So anyway, great meeting. Be there.

I think you'll really enjoy it. We had a great meeting last week in Chicago, what was called the Great Lakes meeting, and we're going to repeat that in the next few weeks as well. So this week at the top of the news we have a report from New England Journal yesterday about treatment of latent TB, specifically compared the outcomes of the standard regimen isoniazid for nine months compared to the alternative regimen of four months of rifampin. Previous to this, it was known that isoniazid nine months was grade A evidence and that rifampin was grade B evidence and that isoniazid for six months was grade B evidence. This is a trial of patients with LTBI over six thousand patients I believe who received either four months of rifampin at ten milligrams per kilogram up to a dose of six hundred milligrams or nine months of isoniazid five milligrams per kilogram, again, to three hundred milligrams per day.

It was a non inferiority trial and yes, rifampin was not inferior to the standard of isoniazid, but rifampin had a better completion rate and had less overall toxicity suggesting that the shorter regimen of rifampin might be the better way to go. Shorter regimens are being recommended. A lot of experts are using them. At this last week's meeting in Chicago, Doctor. Kevin Winthrop gave a fabulous talk on management and prevention of infection when talking about LTBI.

He said his preferred regimen was his three HP, a high dose isoniazid and rifapentin given once a week, for three months. Better tolerated, again, shown to be non inferior to isoniazid nine months at standard doses, but a better completion rate and better safety. They're using a handful of pills, it's given once a week, and the doses are out there and published up to nine hundred milligrams a week of rifampin up to nine hundred milligrams a week of, of isoniazid. That's rifapentin not rifampin. They're almost the same.

So think about that when managing patients with latent TB, a positive PPD or positive QuantiFERON, no signs and symptoms, and a negative chest X-ray. If they're going to be on a biologic, and they have our diseases, they really need to be prophylaxed. Interesting report comes from the Journal of the American Academy of Dermatology. This is a look at the risk of developing psoriatic arthritis and psoriasis patients. Specifically, it's a meta analysis of almost a million individuals and shown that the risk of developing psoriatic arthritis was twenty percent.

Now often quoted is a number of around that or thirty percent by Dafna Glideman, but this has got a lot of numbers behind it and it's a pretty reliable study it looks like. What I liked about this also was the risk in children and adolescents who had psoriasis and there the risk of psoriatic arthritis is only three point three percent. Good news for Pfizer and tofacitinib. This week the EU, specifically the EMA approved the use of tofacitinib in adults who have active ulcerative colitis not otherwise responding to DMARDs or biologics. Again, it's a ten milligram BID dose mirrors what's happened here in The United States, further expanding the use of a JAK inhibitor now outside of arthritis.

So this is sort of good news, and this seems to work fairly well according to the gastroenterologists. Another interesting study comes from the Mayo Clinic and Eric Madison's group, where in the Journal of Rheumatology, they talked about their cohort of four twenty nine gout patients who were followed over time, and they showed that when they were hospitalized, gout patients had a tenfold increased risk of developing a gout attack. We see that all the time, but I don't know if you ever had a number associated with that and that's a tenfold increased risk. That's sort of substantial, but more important may be the fact that if they did have a gout attack while being hospitalized for any reason, that it lengthened the stay of hospitalization by an average of one point eight days, two days. That's at a considerable cost.

This speaks strongly to the fact that we need to be aware of this complication, we need to, have these patients in good shape and then quickly treat them so they don't incur more costs and longer hospitalizations. Another interesting study on gout and its consequences comes from The UK and Taiwan where they looked at over a million individual, I'm sorry, a hundred thousand patients who have gout and incident gout, and specifically looked at the risk of having downstream joint replacement surgery. Turns out that in the two databases, one there was a fourteen percent increased risk, the other a fifty six percent increased risk of having subsequent total joint replacement. The sad and interesting thing about this is that for those patients who are on chronic urate lowering therapy, the rates were no different. That what seemed to be effective gout management didn't prevent the subsequent need for joint replacement.

I think that actually speaks to either a different biology of gout, may very well speak to the gout still isn't very well managed, not by those who are managing most cases. So there's a lot of suboptimal management that's going on. I think that again, this is a call to action for primary care and rheumatologists and those who are involved in gout care. Positive results comes from a interesting study out of Israel reported in Reuters this week that the phase three study of RHB-one hundred four gave very good results in patients who are getting RHB-one hundred four for their Crohn's disease. What is RHB-one hundred four?

Well, it turns out to be an anti mycobacterial drug, antibiotic drug with anti inflammatory properties that in phase two trials look fairly good and it's now been mirrored in a phase three trial. The idea here is the hypothesis is that Crohn's disease may be caused by Mycobacterium avium paratuberculosis for which this RHB-one hundred four is highly effective. Well, why is this interesting to me, the rheumatologist, and to you, the person who's listening to the guy who might be interested in this? Well, it speaks to the similarities between Crohn's disease and rheumatoid arthritis. I've always had the crazy suspicion and I'm full of them as you know, that rheumatoid arthritis is ultimately going to be proven to be an infectious disorder, with a therapy that was otherwise overlooked that would treat that infection.

Now whether that's a mycobacterial species or viral species remains to be seen but I'll be proven sometime right in lifetime and when I'm not you'll remind me of that I'm sure. But I think that I like the parallels here I think it'll be interesting to see how this proceeds in the management of Crohn's disease. Looking at several large databases out of Korea, and looking at almost seven thousand consecutive hip and femoral fractures, the risk of having an atypical femoral fracture was shown to be two point nine five percent. That included ninety sub trochanteric and one hundred and six femoral shaft fractures. Risk factors for these atypical femoral fractures was osteoporosis, osteopenia, rheumatoid arthritis, abnormalities in the curvature of the femur or the thickening of the femoral shaft was a prognostic sign of some sort.

But this is data coming from Osteoporosis International and speaks to something that we see as well and that this is still a very uncommon phenomenon. A nice study out of, either The UK or France, I think it's France, but they're close by and the data are probably the same in both countries. Seventy two patients with ankylosing spondylitis or rheumatoid arthritis who went on to switch from the originator etanercept to the biosimilar SB4, etanercept biosimilar, showed that there was a very favorable experience, good switchover, good experience, positive experience as viewed by the patients in eighty five percent of those cases. However, fifteen percent, not so much. Who were those people?

Well, it turns out they were older, had more established disease, were obviously Chicken Littles because they were worried about generics and that was one of the reasons why they didn't want to switch to this generic kind of biologic drug. Again, I think these are lessons to be learned as we are going to adopt biosimilars in the future once we get over this rebate system and incentivize use of existing biologics. When that's fixed by the current administration, maybe. We'll see biosimilars have some growth in The United States, but it's going to be an uphill road and it's going to be fostered by physician attitudes and patient attitudes which is what's operative here. What we've learned by looking at what's going on in Europe is that when they're forced to make changes, everyone benefits.

The docs ultimately don't get so wigged out about it. The patients accept it. Everyone does well. And there's significant cost savings. What they're offering us here in The United States so far is not what's being offered in Europe.

And I think that, until that changes, we won't be seeing many biosimilars in use. So where are we? Another thing that won't go away in the news is opioids. A report from the British Medical Journal looked at Medicare use of opioids and shows shamefully that the opioid use problem isn't going away and that our use of opioids still remains high. That while the plateau in prescriptions and overdoses, seems to have plateaued prior to 2015, that the equivalent use of Methadone or Morphine units still remains high and in fact it may be going up such that the quote from the article is that The United States has the per capita highest rate of opioid use in the world.

Double that of second place Germany and seven times that what's being used in The United Kingdom. On average forty people die every day from an opioid overdose in The United States and that still is fourfold higher than the rate that was seen in 1999. These trends are disturbing. So disturbing that the New York Times has a sort of, feature article on what's happened during this opioid, crisis, and they're finding that there's more use of intraspinal Depo Medrol injections. A very long article but very eye opening shows that in the wanting to stay away from opioids, a lot more doctors are opening up these clinics where they're giving intrathecal, perispinal facet and or epidural injections to relieve alleviate back pain.

And it turns out that this is not really with the consent or wishes of the manufacturer, which is Pfizer. Pfizer went to the FDA pointing out that there was a lot of off label use and that was associated with a lot of adverse events and the FDA's response to this several years ago was to issue stronger warnings against off label use and what the risks may be. Well, a review of FDA data between 02/2016 discloses over 2,400 serious problems arising from Depo Medrol intraspinal injections and that includes one hundred and fifty four deaths. So Pfizer's not behind us, they say they can't control off label use, but what's going on is that Medicare spending for this has gone up. Medicare providers that are issuing these kinds of injections has gone up.

Even in the VA system, the number of such injections has gone up. So that now Depo use has actually gone up 35% between 2015 and 2017 equaling out from a $133,000,000 in sales to a $185,000,000 in sales. That's Depo Measure All and other versions of that. So this is really eye opening sort of stuff and it comes from us and from the New York Times. What about women who have rheumatoid arthritis and the risk to their offspring children?

I don't know what you say. Generally said that the risk seems to be quite low but this is a Danish study that looked at over two thousand one hundred women with rheumatoid arthritis and compared them to one point three million who did not and looked at what the outcome was as far as autoimmune disease in the offspring. What they showed was eye opening that in the offspring of women with RA there was an increased risk of these events, actually was one point seven percent, had RA versus zero point seven percent in those who didn't have RA would have, subsequent rheumatoid arthritis in the offspring. Turns out the hazard ratio of the offspring having RA is two point six nine, for thyroid disease two point one nine and for, epilepsy one point six one. There are a few others scattered in there not significant.

This is very eye opening. I'm gonna end with a Twitter poll that I did this week. What would you prefer when your doctor walks in to greet you? Hello, a handshake, a fist bump or a hug? The poll with a 100 responses say 54%, 45% say want a hello, 45% want a handshake, 5% want a hug, and 5% want a fist bump.

So if you're hugging your patients right out, right as soon as they enter the room, you're probably creeping them out. If you're giving them a fist bump, you're getting quizzical looks. Go with the handshake and say hello. That seems to suffice for most people. That's it for this week at RheumNow.

Go to the website to see this and more. Tell your friends about the podcast. We'll see you next week.