RheumNow Week In Review -The Temporal Artery Biopsy Letdown %284.6.2018%29 Save

It's the 04/06/2018. This is the RheumNow we can review. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. This week, we're gonna talk about what happens when the temporal artery biopsy lets you down, who not to sit next to you on the plane, and who are those people with a mask?

Maybe you should talk to them. And lastly, is it good news when there's no change in the cost of care in rheumatoid arthritis? The top of the news is a nice study by the Swiss. They looked at two forty four patients with rheumatoid arthritis and axial spondyloarthritis and compared them to healthy controls. They showed that our patients who have RA and axSpA have a higher risk of pregnancy, adverse outcomes, including gestational diabetes, preeclampsia, infection, small birth weight, and preterm delivery.

Turns out it's all about disease activity. It is disease activity that drives risk, especially for preterm delivery. This activity gives you a fourfold higher risk of preterm delivery in rheumatoid arthritis and a 14 high fold higher risk of preterm delivery in the XBOB group. So again, focusing on disease activity is the most important thing when managing patients who are pregnant. An interesting study comes from Harvard and their use of the EMR in monitoring their RA patients.

Jeff Sparks and his colleagues looked at about 170 RA patients and focused on one hundred and sixteen, the majority, who had either BMI evidence of obesity or being overweight and looked at outcomes according to what happened to their weight. Turns out there was thirty one patients who lost more than five kilograms of weight, and this this group of of those who lost weight had a threefold higher odds of actually achieving significant disease improvement as defined as a CDAI of equal to or greater than five point change for the better. So, again, it's very important data. It it should should be fuel for you to counsel your patients about the benefits of losing weight, especially if you have an inflammatory disease like rheumatoid arthritis. A study from the Scandinavian Journal of Rheumatology looked at what happens to the total cost of care, what happens to care overall in two different timeframes separated by ten years.

They looked at these two cohorts that either began in 1996 or 2006 and showed a number of interesting observations. What decreased disease activity, sick leave, and hospitalizations when you compare 'ninety six to 2006? What increased was DMARDs and the cost of drugs. What didn't change was the total cost of care, which was about 12,000 to €13,000 in both timeframes and not significantly different between the groups. So while there's not much change in the cost of care, there's a significant shift with more aggressive therapies, more expensive therapies being used, and better disease control.

But while that may cost a lot more money, what the savings are in hospitalizations and surgeries. So that's sort of good news, I believe, for rheumatoid arthritis overall. A study of enthesitis JIA looked at what happens to those patients over time. Turns out at the onset of their disease, a cohort of one hundred and fourteen enthesitis JIA patients, that almost none of them had axial disease or sacroiliitis at the outset. But when they were followed for five years, they did change and a subset of them did change to develop, those two manifestations.

Turns out that after a mean of two point six years, sixty three percent developed axial disease and forty seven percent developed imaging evidence of sacroiliitis. Those more likely to do so are those who had a history of SPA with sacroiliitis in the family and those who had active disease, both imparting a threefold higher risk of developing either axial manifestations or sacroiliitis in those with enthesitis related JIA. So what do you do when you have a negative temporal artery biopsy? It is the gold standard when diagnosing giant cell arteritis. It has a diagnostic yield of eighty five to ninety two percent is what I remember.

And there's a nice study from, clinical rheumatology. They looked at one hundred and fifty four patients who were, included by having a negative temporal artery biopsy for suspected GCA. Turns out that twenty percent of these patients ultimately were diagnosed with GCA. Those that weren't either had neurologic disease, self limited disease, or no diagnosis. But again, twenty percent went on to GCA.

You were more likely to make the GCA diagnosis or the negative temporal artery biopsy if you met ACR criteria for GCA. That gave you a 13 fold higher odds of actually achieving a diagnosis. Or if you had a prior clinical diagnosis of PMR, a three fold higher risk, or evidence of thrombocytosis and elevated platelet count, one point three fold higher risk or thirty percent higher risk. So again, all is not lost when the temporal artery biopsy is negative. Look at the ACR criteria and the platelet count.

An interesting study comes from a sequential study of patients being seen in a GI IBD clinic. So these are patients with Crohn's disease and ulcerative colitis. And they were compared, about two hundred of them, were compared to about one hundred who are followed in the urology clinic with no diagnosis of either IBD or low back pain or any kind of spondylitis. They did CT scans on all these patients and they found that on the controls, the GU patients, five point six percent actually had evidence of sacroiliitis on CT scan. But in the IBD patients, was threefold higher, fifteen to sixteen point nine percent, the higher being the UC patients.

Again, these numbers are sort of in line with what you expect in an IBD population, small subset, close to twenty percent that may actually develop axial disease of some sort, but that you can find it by secretly it is. They didn't look at B27 positivity, they didn't look at symptomatology here, it's just how many developed secretly it is or had secretly it is when you looked at the CT scan. I think that's somewhat instructive. There's another study that looked at patients who have IBD and shows that three million patients we know in The United States have IBD. What is their risk of actually developing a myocardial infarction?

Well, there's a very large cohort of twenty two million IBD patients, and it shows that they have a twofold higher odds of developing a myocardial infarction when followed over time, suggesting it's inflammation. It doesn't have to be rheumatoid. It can be any kind of inflammatory disease that actually is at a higher risk of developing cardiac complications, especially myocardial infarction. Myocardial infarction was also looked at in claims database study looking at is cardiovascular events more frequent with one drug or another. These are patients starting either tocilizumab, about six thousand patients, or Avatacep.

These are claims data from Medicare, elderly people, but then younger people with pharma metrics and IMS and market scan commercial databases. And again, large numbers, six thousand two hundred versus fourteen thousand plus patients. And in the end, they found no higher risk of cardiovascular events with either drug comparing tocilizumab to abatacept, the hazard ratio was 0.82 and an overlap with one suggesting no difference between the two. This is important because many people are concerned about tocilizumab and maybe it might have a higher risk because of its association with hyperlipidemia in twenty percent of patients. But turns out that that's not clinically important.

We do know those patients also significantly drop their CRP levels. We also know there's another state study called INTRACT that was what we reported on last year, and that was a head to head three year trial of tocilizumab versus etanercept looking specifically at lipid levels and cardiovascular outcomes. And while lipid levels did go up in the tocilizumab group, there was no difference in cardiovascular events between etanercept and tocilizumab. And we do know from many studies that chronic TNF therapy does lower cardiovascular event rates. So again, I think this data from the claims data on tocilizumab versus avatarsib is encouraging.

There's an interesting study looking at NXP-two antibodies. I don't if you're aware of NXP-two antibodies, but they are found in a subset of patients with dermatomyositis who may or may not have calcinosis and who may be at higher risk of developing cancer. It's sort of like the TIF1 antibody that's associated with myositis and cancer, but this is NXP2. But an interesting study comes from looking at fifty six patients who have this, eighteen of whom did have calcinosis, thirty eight of whom did not have calcinosis. And the interesting part of the study is they showed that NXP-two positivity, they all had positivity, but titers actually correlated with disease activity for their myositis, but only in those patients without calcinosis, not with calcinosis.

So I think it suggests that NXP-two can be used to define a different phenotype of dermatomyositis patients who without calcinosis, the NXP-two antibodies may correlate well with these activities. It'd be nice to see this repeated in another study. A study comes from the JIA literature looking at IL-six inhibition in patients with Still's disease or systemic onset juvenile idiopathic arthritis or systemic JIA. This is a study from the German aid registry, the Auto Inflammatory Disease Network or registry, where since 2009, they've enrolled over two hundred patients with systemic JIA. They found a subset of these patients who were treated with tocilizumab and looked at their outcomes.

What they found was that in twelve months, thirty five percent had no disease activity and had done very well. Sort of a low number, but it's a stringent definition of no disease activity. By twelve months, it actually had increased to as high as seventy percent, had significant improvement with IL-six inhibition. So I think that this data is somewhat instructive. The question is who should really get IL-six inhibition?

When he did a subset analysis, they found the highest response rates in those who had polycyclic JIA. Eighty one percent in fact responded. Fifty nine percent responded if they had monocyclic JIA, and only twenty nine percent responded if they had polyarticular JIA. I came up with those definitions back in the 80s in my first report on Still's disease, where I characterized the disease as being polycyclic, meaning many spikes of systemic disease often with disease free intervals or monocyclic, an initial spike and activity of inflammatory systemic disease, serositis, high CRPs and ferritins and all that kind of stuff, high fevers, etc. But there's a subset of patients who have chronic articular disease and they may not respond as well.

That might be a good indication for guiding your therapy when trying to choose IL-six inhibition versus IL-one inhibition in someone who has new systemic JIA. There's a nice report about ILD and how to treat those patients with ILD when they have the antisynthetase syndrome. These inflammatory myositis patients who have an interstitial lung disease. And this is a two center study from University of Pittsburgh, Chad Otis's group, and Paul Dell'Aripa at the Harvard affiliates that looked at their cohort of patients, I believe it was fifty six patients, who were treated with rituximab. And what they found was significant improvements in a number of different variables when they follow them over time.

So looking at a twelve month outcome comparing pre rituximab to post rituximab, they showed significant improvement in CT scores, that's a CT scan scores, forced vital capacity, total lung capacity, and steroid use. So I think this is sort of good data. Again, it's uncontrolled data. It's it's there's a limitation to that, but it's hard to find good data on these rare syndromes and this subset of a rare syndrome. This should be good fuel for another study going forward.

Another important report came out this week in the Alzheimer's disease where the SHARE group, this is a group of European investigators developing guidelines and recommendations surrounding the treatment of pediatric rheumatology patients, they came out with guidelines and recommendations on uveitis in JIA. The bottom line is screen everybody and treat them early. The risk factors for developing uveitis in JIA include early onset of arthritis, the oligoarticular subset of JIA, and the presence of an antinuclear antibody. In their report, they give you recommendations about screening, monitoring, diagnosis, and treatment. They show you all the options.

You look at treatment if you wanna find out more about this, But they basically say that patients should be screened early and locally and as soon as possible as the diagnosis of JIA is made. They are noncommittal about the frequency of screening, suggesting that that should be dictated by the disease activity of their arthritis. They are clear in stating that if you stop immunosuppressant or anti inflammatory therapy, you should promptly screen them and screen them every three months for at least a year because that's the period which are more likely to have flares or the onset of uveitis in JIA. I'll end with a quote, a famous quote coming from one of my blogs from this week. And this is a blog about the least favorite patient and how you should approach patients who are your least favorite or who are hard to manage and who you have a problem with relating to.

The quote is providing medical care is more about a commitment to the patient than a commitment to science. When we see these patients, we often know exactly what to do. We're in the know it alls. Should be no discussion, but that's not what works in such patients. Empathy, understanding, and listening are often required and again hard to do, especially when you think you know all the answers.

But again, I think it's an instructive piece and maybe worth a read. That's it for this week at rheumnow.com. Go to the website to find the links to these reports. Be sure to tell your friends to listen in on on on their next podcast that they can get on their iPhone or their Android phone, either on iTunes or on Stitcher. We'll see you next week at roomnow.com.