RheumNow Week In Review RheumNow Live Meeting Announcement %289.21.18%29 Save

Hi. It's the 09/21/2018. This is the RheumNow we can review. I'm doctor Jack Cush, executive editor of rheumnow.com. This week in the news proliferating, profitable, and totally unproven stem cell clinics.

Pregnancy and psoriatic arthritis, is there good news or not? Got milk? Got osteoarthritis? What's the association? We'll cover it here.

But first, an announcement. RheumNow is proud to announce RheumNow live, our first CME meeting that'll be held next year in 2019, March 22 beginning Friday afternoon, all day March 23 on Saturday, and a half day March 24 in the morning. We're going to have sixteen hours of medical education, novel programming, truly novel programming that will not only be broadcast live, but will be interactive. There'll be a lot of networking. We'll be streaming both during the meeting and after the meeting.

I think you're gonna find this a meeting apart, something like you've never seen before. We're gonna have prelearning modules. We're gonna have a flipped classroom design. We're gonna have pods with focused education and long and intensive panel discussions with a highly experienced faculty. And we're gonna have TED like talks from some of the greatest educators that we have in our discipline that will intersperse throughout the program that will make this truly novel.

You can go to roomnow.live to learn more about this meeting and as we unfold it, as we fully, develop our our program and our faculty. It's gonna be exciting. I think you're gonna love it. At the top of the news, we wanna congratulate Beth Jonas. She's the new chief of rheumatology, allergy and immunology at the University of North Carolina School of Medicine.

Beth is well known to many rheumatologists. She's been the interim chair for a while and has well established career in rheumatology. She's got a diverse set of interests. She's a great leader, a great asset to UNC. Congratulations to Beth.

Psoriatic arthritis, you know, we know a lot again about we've been covering this last few weeks, a lot about pregnancy and it's good that that this is getting flushed out to teach us more about pregnancy. An interesting study comes out about thirty five pregnancies and twenty five patients with psoriatic arthritis. Not a lot of data, but important data. The most important thing is that most of these patients did well throughout their their pregnancies, but as would be expected in many inflammatory arthritis or autoimmune conditions, they all tend to flare postpartum, the vast majority after six months. The interesting thing was that of the two thirds that were on biologics, discontinuation of biologics was uniformly associated with the flare of disease activity.

However, the one third that didn't discontinue their biologics, they all actually did well and had no flare of activity. There's something to be learned there. Again, you don't have to stop a biologic, especially if someone has had more recently aggressive disease. It's not the biologic that's dangerous, it's maternal disease activity that's dangerous to both the patient and to the offspring. The MMWR actually has covered, a number of different, musculoskeletal issues over the years.

And a recent review of their NHIS survey shows that in 2016, twenty percent of US adults had chronic pain. Eight percent of that pain or almost a third, more than a third, is high impact pain, meaning it's associated with mobility. What's interesting about this besides being associated with poverty, less education, those who have public health insurance, is that pain costs The US society $560,000,000,000 a year in direct medical costs, lost productivity, wages, and disability. It has this tremendous impact on society. And now we have this opioid epidemic which is making everybody freak out about pain and patients and their pain are not getting treated.

This is really becoming a crisis. This is a major public health issue countered by a major public health scare in the opioid epidemic. Something has to be done. I'm sure you, the rheumatologist can solve this. What about chronic pain?

It's an issue in a lot of arthritis, especially in axial spondyloarthritis. A bit of research looked at those who have chronic axial spondyloarthritis who have ongoing pain. If they originally had an MRI of the SI joints that was found to be negative, repeat MRIs were shown to be of no value. This is sort of common sense medicine, but we need good research to sort of point out where to go when making these decisions in practice. An interesting study comes out looking at a measure I didn't know about, Galectin-nine and its association with other markers and potential biomarkers in lupus for disease activity, including the chemokine CXCL 10, the type two TNF receptors circulating TNF receptor.

They looked at patients with lupus, APS patients, APS and lupus patients, and they showed that these all tend to correlate well with activity. However, GLECTIN-nine was better than double stranded DNA and the other measures in correlating with an overall, alpha type one interferon score. As you know, lupus is hard to characterize and, I believe as many of you do, lupus is a number of different diseases and there's good research that suggests there's a subset of lupus patients that have, driven by type one interferon making, you know, B cells go crazy through, plasmacytic dendritic cells, etc, that really amplify their response. Knowing who those patients are may help to better define what their therapy is going to be in the future. Last week, there's a very important dermatology congress going on in, Paris, it's the EADV conference.

A number of different reports. One I thought was interesting was two products being developed by Pfizer, a JAK3 inhibitor and another TYK2 JAK1 inhibitor being studied in a number of different disorders, but they have good new data on patients with alopecia areata, not the most severe alopecia universalis, but just alopecia areata. Twenty four week data showed significant reductions like 0.0001 or less, significant improvement in their disease activity score and measured as early as week six. So again, this is another area of right development more in the JAK family, includes TYK2 as a potential new therapies. Today, we reported on RheumNow the results of a study coming from the Journal of Nutrition called the Maastricht study that looked at dairy intake and the risk of osteoarthritis.

It's often been stated there's an inverse relationship between osteoarthritis and dairy intake. And they looked at this in over 3,000 normal controls in the Maastricht study found that about fourteen percent of those patients had ACR defined knee osteoarthritis. And what they showed in this very extensive survey, 253 items done repeatedly, that dairy consumption, especially full fat dairy and hard cheeses, what's called Dutch cheeses, includes Edam and a few others, but not milk was associated with about a thirty percent reduction in the risk of knee osteoarthritis. I think this is good data. It's actually repeat some of the data that's been shown before.

There's an argument about whether milk should be included in this mix or not or whether yogurt should be included in this mix or not, but there seems to be consistent story here that dairy is associated with a risk of osteoarthritis, not inflammatory arthritis. If you haven't seen the JAMA article, you should go to the RheumNow website, click on the link. The title of the piece is called Unproven but Profitable Stem Cell Clinics. It's a really nice viewpoint that really discusses this issue of the proliferation of the stem cell clinics in The United States and what the FDA is doing about them. Again, the numbers are staggering.

I think the numbers are something like this 300 2016, there's three fifty one companies marketing stem cell products and preparations to, you know, over 600 clinics. And the estimates are that this number is going up by a 100 a year, that currently there's probably more than seven fifty stem cell clinics. Again, largely being marketed towards the treatment of musculoskeletal disease, especially osteoarthritis, knee osteoarthritis, and yet the proof of their efficacy is nil. And again, they point out that their proof is patient testimonials rather than well designed studies. Now mind you, there are studies that are going on in this arena, and we await those, and they're being done by good academicians in the orthopedic world.

But there's such tremendous profit. These are largely cash only businesses. They are sometimes covered by insurance, but most of these are self pay, and patients really believe in it. It doesn't help that they're they're also being marketed to celebrities and athletes and whatnot, much like PRPP and others, for injuries and repair. So again, and it's not just in musculoskeletal medicine, they're being used for Parkinson's and better vision and Alzheimer's.

And again, the claims are a little bit crazy, but, you know, I think that you'll see that the the the brief synopsis that we provided, the JAMA article, gives you a taste of what's going on in this world. You see these patients as I do, but it's good to know what the data is. There's an interesting study that comes out of Israel about the association between giant cell arteritis and inflammatory bowel disease. In Israel, they looked at claims dataset of three thousand nine hundred and thirty eight patients who had GCA and matched them against twenty one thousand match controls. And they found that the GCA patients had a significantly higher association between it and Crohn's disease and or ulcerative colitis, somewhere between a four and six fold higher rate.

Turns out that the odds ratio was highest in middle aged GCA patients, so was probably around fifty ish or more, whereas the elderly, those greater than 65 had a lower association. So it was eight point one for middle aged GCA patients, but it was only three point eight for elderly GCA patients. Nonetheless, this is something to consider that in your patients who have GCA, it probably would be reasonable to enforce the health maintenance practice of getting regular colonoscopy and probably even force the issue more so if patients are having symptoms that might be construed as possibly being due to inflammatory bowel disease. So it seems like this issue is about the crazies. Let's talk about breast implants and musculoskeletal disease.

Those of you who went through this in the eighties and nineties as I did, found that there was a lot of hysteria about, silicone, coated breast implants maybe giving rise to autoimmune disease. These were taken off the market for a lot of reasons, but there was no proof back then as there probably still is no proof, of an association with autoimmune disease. In 2012, the moratorium was was lifted, and now we're back into an era where it's not just saline implants, but there's also silicone implants. So the Annals of Surgery reported a study of over 99,000, almost 10,000 patients, that they studied, fifty six percent of whom were had received, first augmentation mammoplasty with silicone implants. And they compare the incidence of a number of different disorders that included autoimmune, and they unfortunately compared that to, normalized population data as opposed to a well matched control.

And they found higher rates of Sjogren's syndrome with an SIR of eight point one, scleroderma of seven point o, rheumatoid arthritis of five point nine, stillbirths four point five, and melanoma three point seven. Again, these are in the study felt to be significant, but there's a car at the same time, a corresponding editorial from the FDA saying this data should be viewed with a lot of skepticism. It's not a well designed analysis. These are post marketing studies required by the manufacturers for which they drew their data without any good controls, without appropriate controls. And again, this is going to create some degree of hysteria that you should be aware of.

Lastly, we'll end with, I think an interesting proposal from a French group. This is reported in JAMA of a new classification scheme for patients with idiopathic inflammatory myopathy. What they did in their network is they identified two sixty patients who had complete data, and they analyzed their data for the cluster analysis and they came up with a scheme that's different from the classic Bohann and Peter classification, you remember is classic PM, classic DM, DM associated with malignancy, myopathy associated with connective tissue disease, childhood, etc. They instead narrowed their classification scheme to four categories. Number one, inclusion body myositis, number two, immune related necrotizing myopathy, number three, dermatomyositis, and number four, the antisynthetase syndrome.

That comprise the vast majority of their patients. They may be faulted for not including children in their analysis and maybe that would change things. But I think this is a, they tried to base their analysis based on, the pathology, the immunology, serology associated with these clinical syndromes and came up with these clusters that may have, some, guidance potential going forward. That's it for this week. We're at roomnow.com.

Be sure to tune in. Be sure to come by our booth at ACR where we have a lot of exciting exciting things happening. We'll tell you about that in the next few weeks leading up to the meeting. Have a great weekend. Goodbye.