RheumNow Week In Review Medical School Advice %289.7.18%29 Save

It's the 09/07/2018. This is the room now we can review. Hi, I'm Doctor. Jack Cush, Executive Editor of roomnow.com. This week advice on allopurinol dosing.

How about some advice on how to assess and monitor patients with lupus? Even better advice on going to medical school. Let's start out with a report on methotrexate and psoriasis. I don't know about you, but I'm sort of against using methotrexate and psoriasis. I don't think it's all that effective.

It's certainly not that effective in psoriatic arthritis. It does work in skin psoriasis. It's probably worth a try, but really what's the data and should rheumatologists know this? Well, there actually have been several trials that have shown low level of efficacy and there's one that was recently reported in the literature. It's a study of a 100 and twenty patients who are methotrexate naive and who had active, plaque psoriasis and were randomized to receive either placebo injections or subcutaneous methotrexate that was escalated to a maximum I think around twenty two or twenty five milligrams, after eight weeks.

The endpoint was sixteen weeks and the outcome was the usual Posse 75 outcomes. What they showed in this trial was that at sixteen weeks, methotrexate was more efficacious than placebo with a Posse 75 score of forty one percent and a 10% PASI 75 score in the placebo population. While this is a positive result and certainly merits use in patients with cutaneous psoriasis, It is a low level response, especially when you consider some of the astronomical numbers seen like over eighty percent with the IL seventeen and IL twenty three inhibitors, where they're actually showing, PASI 90 and PASI 100 scores that are quite impressive, often more than fifty percent. This is good, but this is not great. And what's good in the world of psoriasis and psoriatic disease, control of skin disease can be great.

So I think you should know this data. It may be required to use this dose. But then again, there are greener pastures beyond methotrexate. An interesting study comes in from the really the renal literature looking at patients with chronic kidney disease CKD, who are on allopurinol. This is a study of a 114 patients in a single clinic that were followed, and these patients who had renal insufficiency is defined as a GFR of less than 45 cc's per minute were studied.

Turns out all these patients were on allopurinol. The mean dose is a hundred ninety two, two hundred milligrams a day ranging from fifty to four hundred and fifty, and half these patients actually had a diagnosis of gout. However, not all these patients actually met a target dose, a target urate, level of six point zero or less. In fact, it was less than fifty percent. And again, while I don't think this is a great study, I do think this is an important study because it says a few things.

It says mainly that even with patients with renal disease, they're probably under dosing with allopurinol. Allopurinol should be pushed to achieve the target uric acid level rather than worry too much about the effects of allopurinol and renal function. Patients who have above 30 cc's is probably very little effect on renal function when using allopurinol. Doses of four fifty, six hundred or maybe higher are possible in patients who actually have renal disease. An interesting study comes from Jeff Curtis's group, who reported on the utility of tocilizumab in preventing cardiovascular events.

As you know, there's good data out there about, TNF inhibitors and methotrexate preventing cardiovascular death and cardiovascular events. And there's also a warning with tocilizumab that if you use this agent, you may experience hyperlipidemia in up to twenty percent of patients and some of those will actually require therapy. The question is, will this hyperlipidemia associated with tocilizumab or for that matter with tofacitinib be equate to a higher risk of cardiovascular events. As you know, we reported several months ago about the INTRACT trial, which was a comparison of, patients on tocilizumab versus etanercept and showed no difference in cardiovascular event rates. No significant difference in cardiovascular event rates.

Although there were a few more in tocilizumab, it was not significant and that was a three year study appropriately powered. This particular study looked as clinical claims data, looked at over 88,000 individuals, rheumatoid arthritis patients who are taking, a number of different biologics including tocilizumab. It compared the event rate for cardiovascular risk and had a composite definition, for cardiovascular events and they compared tocilizumab to abatacept, rituximab, etanercept, adalimumab, infliximab, and they showed essentially no difference numerically, between rates of cardiovascular events on these different biologics. They looked at an adjusted hazard ratio and showed all of them basically to be one and crossing zero with the only exception being the, infliximab, which had a hazard ratio, adjusted hazard ratio of 1.61, and it did cross and was above one overall suggesting that that might be a risk factor, for cardiovascular events, in patients taking etanercept versus the other biologics. But for tocilizumab, not the case.

That's good news for those people on tocilizumab. What about patients who are, being, treated and monitored for lupus? The Canadian Rheumatism Association came up with, expert guidelines, this past month published in J Room. And these were guidelines made up of by a number of different doctors, including a patient and 23 rheumatologists and others. And they looked at a number of different parameters as far as the assessment of patients with, lupus and also their monitoring over time.

What they came up with I think was instructive. You should look at the citation, they have pediatric rheumatologists on this committee by the way. Number one, said everybody should be seen by a rheumatologist. Two, that they should have a validated regular disease activity measure. They should also be assessed annually for a validated measure of damage.

They suggested patients should be assessed for cardiovascular risk, especially risk factors including smoking, hypertension, diabetes, dyslipidemia, and that should be done periodically. Carotid ultrasound should not be a part of that assessment unless they otherwise have disease. Patients should be assessed for osteoporosis, they should have vitamin D levels assessed if they are on high dose glucocorticoids or have a history or symptoms of osteonecrosis, they should be assessed for osteonecrosis. For women of childbearing age, they should be tested for Roe and Law during their first trimester or prior to conceiving if they're planning pregnancy. For women who are pregnant and have active lupus nephritis, they recommend screening for creatinine and urine protein creatinine ratios every four to six weeks throughout the pregnancy, and less so thereafter.

Sexually active women with lupus should be screened for cervical cancer, every three years at least up until age 69. They recommend vaccination with influenza annually. They recommend screening for hepatitis B surface antigen and hep C virus in patients with lupus. I think we mostly do all those things, but do you do all those things? That's the challenge here and you probably should consider that based on these recommendations from the Canadian Rheumatism Association.

Lastly, I'll end up with a synopsis of a report that appeared in the August 28 edition of JAMA. This was a letter from a physician at the University of Chicago, Doctor. Sifu, where he was giving advice to a student starting medical school. I used some of this content during a recent, white coat ceremony speech I gave, St. George's University in Grenada, and I'm going to sort of excerpt this for you and try to do this quickly.

But I think it's really nice and worth a read, if not worth a listen here. He writes that he sat at his desk trying to write a letter to a student who was actually the daughter of some of his best friends and he wanted to write an inspiratory letter. He wanted something to give her as she went off to medical school, but he's having a hard time finding the words. So while struggling to find the right words, I saw a drawing hanging on my wall. It had been there for twenty five years.

I thought, let me write about that because there's three important lessons in that. I met E, the patient, during my internship in 1993. He was a struggling artist, he was homosexual and he was concerned about being infected with HIV. After taking his history and doing his exam, I recommended HIV testing. However, the patient said not gonna happen.

We argued our physicians about HIV testing why it should or why it wouldn't do it. And this was to become the script that they would reenact every three months for the next three years. At each visit, the patient would say no. So even though he thought that he was failing the patient, that the visits were fruitless, he was actually forming a friendship with that patient. A year later, the patient called him breathless and he was admitted to the hospital, had pneumocystis pneumonia, was diagnosed with opportunistic infection and active HIV, went on treatment for both his health and his immune system were restored and the patient goes on.

What about that painting on the wall? Well, from that actually comes three lessons. Lesson number one, often the most important service we provide a patient is not what we think it is. Meaning it's not just the knowledge and the diagnostics and whatnot. While he thought he was failing his patient, he was in fact forming a therapeutic alliance that would serve the patient well when he needed that doctor most.

He could reach out to him and had a certain degree of trust. There's another student, a story about a man admitted to the hospital with two problems. One, he was terribly sick and two, he hated doctors. Once they made him well enough to talk for himself, he threatened to sign out against medical advice. But there was this third year medical student that was on service who formed an alliance with the patient and really saved his life because he turned that terribly sick individual into someone who stayed in the hospital for two weeks and lived and left the hospital two weeks later.

So while students don't really have much in the way of knowledge and acumen to offer. They have a great deal to offer in interest, time, curiosity, and their ideals. Lesson number two, much of what you are taught is wrong. So your most committed and brilliant teachers will also teach you thing teach you things that will in fact be shown to be wrong later. Could be because of time or because they were wrong from the start.

One of his mentors was a truly great doctor, a committed educator, a well rounded physician, and he had taught him a tremendous amount and was his favorite and, most important mentor. However, I recognized that some of what he taught me was wrong. He taught me for instance that getting close to patients was a dangerous thing and that you shouldn't accept gifts from patients. So six months after met E, after actually six months after I E's admission, I'm sorry, I took a job in a new city. I told E I was living.

He gave me a hug, told me he had a gift for me. It was a special painting. I refused it and today I feel stupid because this was a personal thank you, a non monetary creation of his own, and here I was turning him down. However, years later I was thrilled when he sent me a tube that contained that painting that now hangs in my office. He gave me a second chance to accept the gift in a way I couldn't refuse.

The last lesson is lesson number three, keep a sunshine folder. In it, can stash your notes from patients, pictures, great letters of recommendation, small accolades of a job well done. Ease drawing was the beginning of my sunshine folder. Why do you need a sunshine folder? Because medicine's hard, there are hard days, you don't always do well.

A sunshine folder is always there to brighten your spirits on difficult days that will lie ahead. I commented to the students I had my sunshine folder and I didn't have a name for it, now I do. It has these pictures and these letters and whatnot, but the favorite thing in my sunshine folder is my ugly tie rack. My ugly tie rack is actually a collection of ties given to me by patients who could not afford to buy me ties. These, ties were to say the least interesting and at their worst fashion disasters.

They had bonsai trees on them, they had giraffes on them, the colors were horrible, they were wide, they were skinny, they were from another era, from another solar system as far as the colors, but as ugly as they were, they were given with love and thanks. I collected every one of them, I hang them on my coat rack inside my door. And when I go to work every day, it's there and I notice them and it reminds me of something. Even better is when a not so well dressed faculty member sort of runs into my office hurriedly having an important meeting or an unexpected consult at the hospital and says, I need the I need a tie. And I point to that tie rack and they look at me and they go, really?

Well, you know, they take that tie, and they hope that nobody will will look at them. So that tie rack keeps on giving. I could think this is a really good piece. You should probably look at it in JAMA. That's it for this week.

Go on the website, check out these citations and more. We'll see you next week on rheumnow.com.