The RheumNow Week In Review Modifiable Behavior %285.18.18%29 Save

It's the 05/18/2018. This is the RheumNow we can review. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This week in the news, a new drug for polyarticular JIA.

Opioids are again all over the news and there's a lot of news about modifying behaviors and how it affects outcomes in rheumatology. So this week in the news, we'll start with a study about osteoarthritis and data from the osteoarthritis initiative. This is a ten year study, large study looking at twelve oh three patients specifically looking at a number of, things that may influence x-ray outcomes, clinical outcomes. In this particular study, they examined the effects of self proclaimed running on the outcomes. What they found in men over the age of 50 who had knee osteoarthritis, that self proclaimed running was in fact associated with less knee pain, not worse knee pain, and was not associated with radiographic deterioration and more knee OA over time.

Again, this goes to the data that's pretty well known that running per se does not cause osteoarthritis or cause arthritis in general. When it does, it's because there's an alteration in mechanics, that your mechanics are not normal to the point that the cartilage gets damaged and degraded. But if you have normal mechanics, being overweight doesn't make a difference, and hence running is good whether you're normal or a high weight or whatnot. So I think it's encouraging for those of us who advise our patients with regard to running and what the consequences of that may be. Genentech announced this week that they have a new indication for polyarticular JIA and their drug tocilizumab.

The drug was approved in a subcutaneous form for kids with severe moderate to severe polyarticular JIA, and it's a sub q form that's approved. The doses are for those above thirty kilograms, the dose is gonna be the usual one hundred and sixty two milligrams every other week. For those under 162, it's every three weeks. So it's a little bit different. They're using the same, syringe and materials as we use in adults, but it's just the alteration in schedule according to weight.

Interestingly, that there are differences when you compare the less than 30 to the over 30, the less than 30 again getting it less frequently every three weeks and the 30 getting it every two weeks. Those who had the more frequent doses, there was a twenty eight percent chance of getting actually overall in this study, a twenty eight percent chance of getting ISRs, injection site reactions, a little bit higher than that seen in adults who received tocilizumab. What I thought was surprising was the frequency of neutropenia with poly counts less than or neutrophil counts less than 1,000. This was actually quite common in those under thirty thirty kilograms in weight, twenty six percent versus those over thirty kilograms weight where it was only four percent. So for those that are getting it, every three weeks and, and who are under thirty kilograms in weight, you probably need to watch that CBC a little bit more closely.

Rheumatoid arthritis patients, as you know, have a greater risk of developing vascular complications, including, cerebrovascular events or CVAs. In a study of seven thousand nine hundred patients, they looked at the risk of developing CVAs. They showed overall that RA patients in this cohort had a twenty one percent increased risk of CVA. But they also showed that therapy could modify those outcomes specifically being on methotrexate would significantly reduce the chance of having an ischemic stroke, but only for the first seven years of study. After that, there was no, there's no protection.

In fact, it looked like it might have been slightly higher. It turns out that, hydroxychloroquine and sulfasalazine did not affect the ischemic stroke risk in this study. So this data sort of parallels that seen in the, RA patients who were treated with methotrexate and their reduced risk of cardiovascular events, suggesting again that if you control inflammation, you can now control the vascular consequences of uncontrolled inflammation. Walmart sort of stepped up in the news this week and grabbed a headline by changing its policy. They announced that in accordance with CDC prescribing recommendations that they were going to change or they will change soon their limits on opioid prescriptions such that opioids will only be prescribed for seven days at a time going forward.

This is an attempt to curtail abuse and but is it really or is it an attempt to also contain costs and stay out of the news? Again, I applaud efforts to educate and try to reduce the risk of opioid abuse. The problem is that patients who need medicines for pain are really taking it in the shorts. This is really unfortunate and it doesn't seem to stop. It's getting more and more difficult for people with pain to be adequately treated for pain.

And it's I think a struggle for the clinicians and certainly a big struggle for patients. UAB announced this week that they would be doing the Recipe Trial. Recipe Trial is going to be a relatively small study. I think it's 30 patients or something like that in three centers. It's going be in Tampa and somewhere in the North and also at UAB, University of Alabama at Birmingham, to do the study in gout where they're going to test the utility of background mycophenolate therapy in patients receiving pegilodecase therapy.

As you know pegilodecase is a highly effective drug in patients who have severe recalcitrant tophaceous gout. It's been shown to dissolve tophi and make that elevated uric acid go down to almost undetectable levels. And one of the risks are infusion reactions that seem to go up when patients develop antibodies to the pegylated portion of the molecule and that therefore inactivates the drug, makes it less effective, but also will then lead to a sudden rise in uric acid levels as a sign that you have an immunogenic interference. So one of the ideas, behind maybe more effective ways of using this drug is to give a background immunosuppressant that wouldn't affect the uric acid levels, like for instance, leflunomide, but might suppress autoantibody production. I've done this in patients using azathioprine as has Michael Pillinger, he's sort of published on that a little bit.

But now the company is stepping up and doing a study using mycophenolate as their background therapy. So it'll be interesting to see if this study would shed further light on maybe a better way to use pegvodecase in patients who really need it. There's another study out there about lupus and obesity And it was sort of interesting I thought that obesity is associated with worse outcomes in lupus as it has been shown in other forms of arthritis, mainly inflammatory arthritis, RA and PSA. And here it's been shown that in one hundred and forty eight patients that it was independently associated with worse disease activity, more depressive symptoms, more pain and more fatigue. The bottom line being that like in other disorders, management of nutrition and obesity may be a modifiable behavior that could lead to better disease control, and better outcomes in patients with lupus.

Another lupus study looked at the cardiovascular risks associated with lupus. As you may know, those are increased and turns out that the risk of cardiovascular events is about the same between patients who have lupus or who have diabetes. And when they looked at claims data, for how those patients were treated, They specifically looked at lipid management. They found that using a Medicaid claims database that lupus patients were less likely to be tested for their lipid levels and more importantly, about two thirds less by the way, and more importantly were less likely to fill a prescription, meaning meaning that they weren't prescribed a statin lipid lowering agent than those with diabetes. Again, two percent, of lupus patients received were less likely to receive a statin compared to diabetics were more likely to receive statins.

Again, another behavior by a physician that could significantly change the outcome of our patients with lupus. A nice paper, is out there in JAMA looking at the, effects of marketing on prescribing. As you know, there's very good data that shows that marketing efforts do pay off in prescriptions, which is one of the reasons why we no longer have dinner meetings. We only have promotional dinner meetings because of a number of different factors and watch for that next week in RheumNow. I'll be writing a blog on that.

Nonetheless, analysis of prescribing patterns and marketing prescriptions excuse me, marketing efforts and prescribing and prescriptions written in 2014 and 2015 showed that physicians who were not engaged in a marketing effort that was promotional for opioids, they had their prescriptions go down in 2015 compared to 2014. You'd expect that given the notoriety of the opioid epidemic, etc. However, if physicians had been the target of a marketing effort, such as receiving a meal or being engaged as a consultant, etc, those people actually had their prescriptions for opioids go up in 2015. So it turns out that for those who actually were targeted as far as marketing that they had almost 10 more opioid prescriptions than did those who did not. I guess the bottom line, the number that I thought was sort of shocking was for every industry meal that was consumed, this was associated with a 0.7% increase in opioid claims, meaning opioid prescriptions.

That's sort of, a bit shocking, but that shows you the power of marketing and why even a simple meal, may have undue influence. There's a study out there also looking at what happens in ankylosing spondylitis and specifically women. I thought this is a very interesting study because although it was a small study, it was one hundred and twenty two patients, forty percent of whom had women, they looked at the durability of therapies over time. So these are one hundred and twenty two who went on a biologic, specifically a TNF inhibitor, and they showed that, women had less, durability of TNF inhibitors, they stayed on TNF and it was less than did men. So again, as a ten year follow-up study, a mean follow-up of about five point one years, overall women were more likely to go off the TNF inhibitor.

Their durability was only thirty three months compared to a mean of forty five months in men. Women were more likely to change TNF inhibitors to switch drugs. And although the and those were both significant changes, that were noted for women, and that, not significant, but a trend was that women were more likely to stop all anti TNF therapy than did men. The bottom line here is that women and men with spondylitis are totally different. We that actually because know women are present differently, they are often diagnosed much later, they're often misdiagnosed until late.

Men tend to be diagnosed early and based on classic inflammatory low back pain, etc. Women, it's much later that they're diagnosed. They may also not have just, axial symptoms, may have peripheral symptoms and the data that's very disturbing is that women tend to have a lot more pain with their spondylitis than do men. These suggest that women with ankylosing spondylitis are a significant challenge and one that needs to be met with more research and maybe more targeted efforts, on their behalf. That's it for this week at roomnow.com.

Actually, we'll end with a quiz. The FDA approval of tocilizumab for polyarticular JIA now makes this how many drugs that are approved for polyarticular JIA? I'll tell you that there's 10 biologics that are approved for use in adult rheumatoid arthritis, polyarticular condition, and you know these. Efliximab, etanercept, adalimumab, galimumab, cerdulizumab, abatacip, rituximab, tocilizumab, sorilumab, and anakinra. So what are the, drugs that are actually also approved and how many of these 10 are approved in kids?

I would insert music here that you would get to answer that question and the answer is four. Now with the approval of Tocilizumab we have four biologics that include etanercept, adalimumab, and abatacet. That's it for this week's quiz. Go to the website, look up more about these particular news stories if you wanna see the links and read the whole story. Be sure to tune in next week for more news@roomnow.com.

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