The RheumNow Week In Review - Vitamin D Snark Report %284.20.18%29 Save
The RheumNow Week In Review - Vitamin D Snark Report %284.20.18%29 by Dr. Cush
Transcription
It's the 04/20/2018. This is the RoomNow Weekend Review. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This week, are you ready for the vitamin D snark report, infections and rheumatology, and just where is your salary going?
At the top of the news is fostamatinib. Remember fostamatinib, the sick kinase inhibitor was being tested for rheumatoid arthritis. First two studies look great, but then it sort of crashed and burned at the end and fell off the list. Well, it's resurfaced. And this week was FDA approved for use in chronic ITP.
The drug is gonna be marketed as TAVALISSE, and it will have a new life, but just not in rheumatoid arthritis. An interesting study was published about and this is interesting, I don't know, I argued with my colleagues at work if the active extend study is important or not. It's a study of abaloparatide versus alendronate. And actually it's abaloparatide in the active study, it's a nine month study of abaloparatide versus placebo and not surprisingly showed significant fracture reduction in postmenopausal osteoporosis. But then the extent the extent part of it, the active extend, the open label extension of that took patients on abaloparatide and then randomized them to continued placebo or continued alendronate.
Not surprisingly, the combination of successive avaloparatide followed by alendronate for over two years was met with better BMD results and lower fracture rates. Those who got placebo initially and then alendronate did kind of okay, but, obviously not as bad as probably placebo and placebo. But the idea here is that after a baloparatide and there's a limit there as to how much you can use this just like teriparatide, maybe you could follow it up with bisphosphate and do well. This may be the future of such therapy and abaloparatide and both these drugs in fact are FDA approved currently. Where is your salary going?
Well, Medscape comes out this week with its annual review of physician salaries. And it does give us good news in rheumatology such that your salary, maybe you didn't know it, is up 9% from last year to a mean salary nationwide of $257,000 a year. The mean change or actually the range of changes across the board in all medical subspecialty was as high as 16%. I think it was in psychiatry and as low as minus 9% in general surgery, we all know they're overpaid. But rheumatology did fairly well, sort of in the top third here.
But the interesting thing about this survey, you should go and look at the link and look at the Medscape site, had a lot of data about rheumatologists, their satisfaction, etc. But it says that we're not so high in wanting to pursue rheumatology again, if given a second chance. I think the number was seventy two percent of us said that. That sounds good to me, but not as high as it has been in the past. There's also numbers about shifts in personnel and workforce amongst women, there's a high preponderance of amongst Asians, there's a high preponderance of women amongst whites, there's a high preponderance of older males.
But that's not surprising given the recent workforce study. IGRAs I wrote about this week because most people probably don't know some of the tidbits on IGRAs, that's QuantiFERON and the T SPOT or Ella SPOT tests. Obviously, you know that they are positive in patients with MTB and should be negative in individuals who have a positive PPD related to BCG, because BCG does not have the antigens that are in those IGRAs including ESAT and CFP. Turns out though that most of the non tuberculous mycobacterial infections should also be QuantiFERON or T SPOT negative, but not all of them. And the exceptions are a few that you need to be aware of that.
So it includes M. Bovis, Afrikaans, Kansassi, Solgi, Marinum and Gordoniae give you positive results due to atypical mycobacteria what's now called non tuberculous mycobacteria. Another interesting study comes from a review of HIV positive individuals and what happens as far as rheumatic disease. I sort of was reared in an era when if you had HIV is unlikely you would get RA, but that was when there were not effective therapies and now most people who have HIV tend to have normal cd4 counts, hence more normal T cell function, you could get rheumatoid arthritis. Well, in this review of almost three thousand patients who had HIV and they were on HRT, there were one hundred and thirteen who had been diagnosed with rheumatic disease.
It was led by, you probably didn't guess it right, avascular necrosis in one point three percent. Next highest was psoriasis on the list. Again, it was a very low number somewhere around one percent. There were only seven cases of RA, six cases of psoriatic arthritis, and six cases of lupus. Turns out that, in HIV males were more likely to have a rheumatic disease than females.
So it turns out and these numbers, are they at increased risk compared to the general population turns out hepatitis C did increase the risk of developing rheumatic disease and rheumatic disease HIV individuals tends to be the same as far as prevalence as it would be in the general population. So there's not a predilection for rheumatic disease in these HIV positive individuals. There's an interesting study out this week about the comparison of lupus clinics and general rheumatology clinics. I think we've talked in the past about some of the advantages offered by combined clinics for psoriasis run by rheumatologists and dermatologists. Well, there are people who have specialized lupus clinics and the question is, do they actually get better care?
Well, there's one study that's in the literature that says this is so but they only go so far and they mainly look at quality measures. So when they compare, patients attending a lupus care specialty clinic versus general rheumatology, as far as the quality measures, you're more likely to have them achieved in the lupus clinic, eighty six percent versus seventy percent. There's better anti phospholipid testing, more DEXA scanning, more use of steroid sparing agents and ACE inhibitors. And so I think that that's encouraging, but there's not data about better outcomes, less hospitalizations, less cost of care. That's the sort of stuff we really need to see if we're to pursue this in the future.
A study of over eleven hundred almost twelve hundred patients with systemic sclerosis shows that three point four percent of them get venous thromboembolic events. VTEs are in the news for reasons I'll state later. But they looked at both DVTs and PEs and they showed that amongst these patients, the rate was two point seven per 1,000 patient years. That's very low and it turns out that's exactly what you get in the general population. Anything below five is doing very, very well.
Turns out that in this study, the risk factors for VTE in scleroderma were those who had, pulmonary arterial hypertension, peripheral arterial disease, SCL seventy positivity, and the presence of anti cardiolipin antibodies. And each of these imparted an increased odds with an odds ratio of two and a half to about five and a half, across the board. But the bottom line is VTE is not generally increased in scleroderma unless you have one of these risk factors. VTE is a big issue because it's now in the news, it's going to be studied this week on Monday at the FDA advisory hearing where baricitinib data is going go up in front of a panel and they're going to look at the dose, the efficacy, the safety and they're going to review some VTE data that's been associated with baricitinib use. We have a survey going on on the website that you might want to take a look at some very interesting results.
For instance, where do you see VTE in your patients in your clinic? Is it as a result of surgery? Is it inflammation, obesity, smoking, other drugs or is it cancer? Look at the survey results I think you'll find them surprising we'll write about them in the next week or two. EMA has a hearing this week on or actually is planning a hearing in early June on the safety of quinolones.
They're way behind the FDA on this. The FDA has already had these hearings and made recommendations that quinolone should not be used for routine infections when other drugs exist because of their association with tendinopathies and tendon rupture. The EMA will probably review the same data and hopefully come to the same conclusion. So there are hearings this week at the FDA in Bethesda, there's going to be a hearing on baricitinib and rheumatoid arthritis, there's going to be a hearing to discuss the results, the PRECISION trial with celecoxib, and then a second day of non steroidal hearings, it's gonna look at the overall safety of aspirin with nonsteroidals and nonsteroidal safety overall. This will be the third such big summit on nonsteroidals and we'll be covering this on RheumNow next week.
So vitamin D, it's in the news, it's everywhere. Oh my god, guess what? If vitamin D being low is associated with an increased risk of non infectious uveitis, I'm speechless. And turns out that when you look at the data, was largely in African Americans and not necessarily in Caucasians. I tweeted that if only giving vitamin D supplementation would fix all of the world's evils, that would be a wonderful thing.
Wait, it doesn't just stop there. There's more Just reported today that vitamin D is linked this time to diabetes. Oh my goodness, take the vitamin D and still take a few marshmallows, you'll be okay. Is it possible that the people who take vitamin D are sort of too healthy or too busy to take a Twinkie and hence they won't get diabetes? I don't know.
But nonetheless, vitamin D is all over the news. Actually a reputable report this week comes from the USPSTF, the Task Force on Public Health Service on recommendations for vitamin D calcium supplementation. They actually are against the use of calcium and vitamin D supplementation in individuals, males and premenopausal females who don't otherwise have a need for it. So in their analyses, they excluded the elderly, they excluded those who have osteoporosis, those who a history of fracture, those who have a good reason to take such supplementation. But in others it turns out it's not needed.
So again, all these people and we're finding all these associations with vitamin D, again, I'm going to continue to report them, maybe we'll change our minds about them. A big news for, the auto inflammatory world, Kineret and Akinra was approved in the EU for use in Still's disease, both adults with Still's disease and children with systemic onset JIA. This is I think, an advance, and as you know, right now, is only approved for caps and rheumatoid arthritis in The United States. But we need more studies in this area to know, how well it works. There's actually a nationwide, a worldwide study going on right now of Kinerette in patients with both juvenile and adult stills.
You can go to clinicaltrials.gov and find out where that's going on at your site. If you'd like to refer patients to my site, we're enrolling patients. And lastly, we have a nice report about the shared epitope and smoking association. As you know, the shared epitope gives you an increased risk of getting rheumatoid arthritis. Having shared epitope gives you more severe disease.
And if you're a smoker, that's a really bad combination. The question is why does this association exist? Was an interesting article in PNAS that just appeared that looks at this association. It turns out that smoke is like other environmental pollutants, that these are basically dioxin and others that have been implicated in other autoimmune and animal models of autoimmune disease. It turns out that these hydrocarbons get together with their receptor, and that can drive osteoclast activation and th 17 cells at inflammatory sites.
In this particular study, they showed that mice who had the shared epitope, and then were treated with this hydrocarbon receptor agonist actually led to increased osteoclast activity and the recruitment of Th17 cells to inflammatory sites, resulting in more inflammation, more erosions in an animal model. It's this crosstalk that's going on between, these pollutants and the shared epitope that leads to more severe disease and all this of course is driven by NF kappa B. So again, good news, it takes us one step further in understanding this association, between smoking and those who are genetically at risk for rheumatoid arthritis. That's it for this week. Tune in next week where you'll hear more about the FDA hearings.
Tune in next week where you can learn a lot more good news in rheumatology. See you next week.
At the top of the news is fostamatinib. Remember fostamatinib, the sick kinase inhibitor was being tested for rheumatoid arthritis. First two studies look great, but then it sort of crashed and burned at the end and fell off the list. Well, it's resurfaced. And this week was FDA approved for use in chronic ITP.
The drug is gonna be marketed as TAVALISSE, and it will have a new life, but just not in rheumatoid arthritis. An interesting study was published about and this is interesting, I don't know, I argued with my colleagues at work if the active extend study is important or not. It's a study of abaloparatide versus alendronate. And actually it's abaloparatide in the active study, it's a nine month study of abaloparatide versus placebo and not surprisingly showed significant fracture reduction in postmenopausal osteoporosis. But then the extent the extent part of it, the active extend, the open label extension of that took patients on abaloparatide and then randomized them to continued placebo or continued alendronate.
Not surprisingly, the combination of successive avaloparatide followed by alendronate for over two years was met with better BMD results and lower fracture rates. Those who got placebo initially and then alendronate did kind of okay, but, obviously not as bad as probably placebo and placebo. But the idea here is that after a baloparatide and there's a limit there as to how much you can use this just like teriparatide, maybe you could follow it up with bisphosphate and do well. This may be the future of such therapy and abaloparatide and both these drugs in fact are FDA approved currently. Where is your salary going?
Well, Medscape comes out this week with its annual review of physician salaries. And it does give us good news in rheumatology such that your salary, maybe you didn't know it, is up 9% from last year to a mean salary nationwide of $257,000 a year. The mean change or actually the range of changes across the board in all medical subspecialty was as high as 16%. I think it was in psychiatry and as low as minus 9% in general surgery, we all know they're overpaid. But rheumatology did fairly well, sort of in the top third here.
But the interesting thing about this survey, you should go and look at the link and look at the Medscape site, had a lot of data about rheumatologists, their satisfaction, etc. But it says that we're not so high in wanting to pursue rheumatology again, if given a second chance. I think the number was seventy two percent of us said that. That sounds good to me, but not as high as it has been in the past. There's also numbers about shifts in personnel and workforce amongst women, there's a high preponderance of amongst Asians, there's a high preponderance of women amongst whites, there's a high preponderance of older males.
But that's not surprising given the recent workforce study. IGRAs I wrote about this week because most people probably don't know some of the tidbits on IGRAs, that's QuantiFERON and the T SPOT or Ella SPOT tests. Obviously, you know that they are positive in patients with MTB and should be negative in individuals who have a positive PPD related to BCG, because BCG does not have the antigens that are in those IGRAs including ESAT and CFP. Turns out though that most of the non tuberculous mycobacterial infections should also be QuantiFERON or T SPOT negative, but not all of them. And the exceptions are a few that you need to be aware of that.
So it includes M. Bovis, Afrikaans, Kansassi, Solgi, Marinum and Gordoniae give you positive results due to atypical mycobacteria what's now called non tuberculous mycobacteria. Another interesting study comes from a review of HIV positive individuals and what happens as far as rheumatic disease. I sort of was reared in an era when if you had HIV is unlikely you would get RA, but that was when there were not effective therapies and now most people who have HIV tend to have normal cd4 counts, hence more normal T cell function, you could get rheumatoid arthritis. Well, in this review of almost three thousand patients who had HIV and they were on HRT, there were one hundred and thirteen who had been diagnosed with rheumatic disease.
It was led by, you probably didn't guess it right, avascular necrosis in one point three percent. Next highest was psoriasis on the list. Again, it was a very low number somewhere around one percent. There were only seven cases of RA, six cases of psoriatic arthritis, and six cases of lupus. Turns out that, in HIV males were more likely to have a rheumatic disease than females.
So it turns out and these numbers, are they at increased risk compared to the general population turns out hepatitis C did increase the risk of developing rheumatic disease and rheumatic disease HIV individuals tends to be the same as far as prevalence as it would be in the general population. So there's not a predilection for rheumatic disease in these HIV positive individuals. There's an interesting study out this week about the comparison of lupus clinics and general rheumatology clinics. I think we've talked in the past about some of the advantages offered by combined clinics for psoriasis run by rheumatologists and dermatologists. Well, there are people who have specialized lupus clinics and the question is, do they actually get better care?
Well, there's one study that's in the literature that says this is so but they only go so far and they mainly look at quality measures. So when they compare, patients attending a lupus care specialty clinic versus general rheumatology, as far as the quality measures, you're more likely to have them achieved in the lupus clinic, eighty six percent versus seventy percent. There's better anti phospholipid testing, more DEXA scanning, more use of steroid sparing agents and ACE inhibitors. And so I think that that's encouraging, but there's not data about better outcomes, less hospitalizations, less cost of care. That's the sort of stuff we really need to see if we're to pursue this in the future.
A study of over eleven hundred almost twelve hundred patients with systemic sclerosis shows that three point four percent of them get venous thromboembolic events. VTEs are in the news for reasons I'll state later. But they looked at both DVTs and PEs and they showed that amongst these patients, the rate was two point seven per 1,000 patient years. That's very low and it turns out that's exactly what you get in the general population. Anything below five is doing very, very well.
Turns out that in this study, the risk factors for VTE in scleroderma were those who had, pulmonary arterial hypertension, peripheral arterial disease, SCL seventy positivity, and the presence of anti cardiolipin antibodies. And each of these imparted an increased odds with an odds ratio of two and a half to about five and a half, across the board. But the bottom line is VTE is not generally increased in scleroderma unless you have one of these risk factors. VTE is a big issue because it's now in the news, it's going to be studied this week on Monday at the FDA advisory hearing where baricitinib data is going go up in front of a panel and they're going to look at the dose, the efficacy, the safety and they're going to review some VTE data that's been associated with baricitinib use. We have a survey going on on the website that you might want to take a look at some very interesting results.
For instance, where do you see VTE in your patients in your clinic? Is it as a result of surgery? Is it inflammation, obesity, smoking, other drugs or is it cancer? Look at the survey results I think you'll find them surprising we'll write about them in the next week or two. EMA has a hearing this week on or actually is planning a hearing in early June on the safety of quinolones.
They're way behind the FDA on this. The FDA has already had these hearings and made recommendations that quinolone should not be used for routine infections when other drugs exist because of their association with tendinopathies and tendon rupture. The EMA will probably review the same data and hopefully come to the same conclusion. So there are hearings this week at the FDA in Bethesda, there's going to be a hearing on baricitinib and rheumatoid arthritis, there's going to be a hearing to discuss the results, the PRECISION trial with celecoxib, and then a second day of non steroidal hearings, it's gonna look at the overall safety of aspirin with nonsteroidals and nonsteroidal safety overall. This will be the third such big summit on nonsteroidals and we'll be covering this on RheumNow next week.
So vitamin D, it's in the news, it's everywhere. Oh my god, guess what? If vitamin D being low is associated with an increased risk of non infectious uveitis, I'm speechless. And turns out that when you look at the data, was largely in African Americans and not necessarily in Caucasians. I tweeted that if only giving vitamin D supplementation would fix all of the world's evils, that would be a wonderful thing.
Wait, it doesn't just stop there. There's more Just reported today that vitamin D is linked this time to diabetes. Oh my goodness, take the vitamin D and still take a few marshmallows, you'll be okay. Is it possible that the people who take vitamin D are sort of too healthy or too busy to take a Twinkie and hence they won't get diabetes? I don't know.
But nonetheless, vitamin D is all over the news. Actually a reputable report this week comes from the USPSTF, the Task Force on Public Health Service on recommendations for vitamin D calcium supplementation. They actually are against the use of calcium and vitamin D supplementation in individuals, males and premenopausal females who don't otherwise have a need for it. So in their analyses, they excluded the elderly, they excluded those who have osteoporosis, those who a history of fracture, those who have a good reason to take such supplementation. But in others it turns out it's not needed.
So again, all these people and we're finding all these associations with vitamin D, again, I'm going to continue to report them, maybe we'll change our minds about them. A big news for, the auto inflammatory world, Kineret and Akinra was approved in the EU for use in Still's disease, both adults with Still's disease and children with systemic onset JIA. This is I think, an advance, and as you know, right now, is only approved for caps and rheumatoid arthritis in The United States. But we need more studies in this area to know, how well it works. There's actually a nationwide, a worldwide study going on right now of Kinerette in patients with both juvenile and adult stills.
You can go to clinicaltrials.gov and find out where that's going on at your site. If you'd like to refer patients to my site, we're enrolling patients. And lastly, we have a nice report about the shared epitope and smoking association. As you know, the shared epitope gives you an increased risk of getting rheumatoid arthritis. Having shared epitope gives you more severe disease.
And if you're a smoker, that's a really bad combination. The question is why does this association exist? Was an interesting article in PNAS that just appeared that looks at this association. It turns out that smoke is like other environmental pollutants, that these are basically dioxin and others that have been implicated in other autoimmune and animal models of autoimmune disease. It turns out that these hydrocarbons get together with their receptor, and that can drive osteoclast activation and th 17 cells at inflammatory sites.
In this particular study, they showed that mice who had the shared epitope, and then were treated with this hydrocarbon receptor agonist actually led to increased osteoclast activity and the recruitment of Th17 cells to inflammatory sites, resulting in more inflammation, more erosions in an animal model. It's this crosstalk that's going on between, these pollutants and the shared epitope that leads to more severe disease and all this of course is driven by NF kappa B. So again, good news, it takes us one step further in understanding this association, between smoking and those who are genetically at risk for rheumatoid arthritis. That's it for this week. Tune in next week where you'll hear more about the FDA hearings.
Tune in next week where you can learn a lot more good news in rheumatology. See you next week.
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