RheumNow Weekly Podcast 3 Wiseguy Rheumatologists %2811.9.18%29 Save

Hi, I'm Jack Cush with RheumNow. Before this week's podcast, I want to tell you about RheumNow Live, an exciting new meeting co hosted by myself and Artie Cavanaugh. And we want to invite you to this exciting new meeting that's going to occur March 22 through '24 in 2019 in beautiful downtown Fort Worth, Texas. Easy to get to, a wonderful walkable town. If you've never been to Fort Worth, it is truly distinctive and a real slice of life in The United States.

As a great meeting destination, I think you'll find this to be a great meeting. This is going to be a meeting that we've been working on for over a year. It is the next generation of meetings, meaning it is designed to basically meet the needs of the audience and to have a much greater impact. It is designed to be highly interactive. It's going to be formatted in a different way.

There's going be pre meeting learning assignments between you and the faculty who will communicate with you starting six weeks before the meeting. There's gonna be an app that you're gonna use during the meeting that'll keep you in connection with each other who are in attendance and also with the faculty. We'll use that for, again, highly interactive sessions. Our sessions aren't hour long sessions, they're only thirty minutes long. And we're gonna have what we call pods or dedicated sessions for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, lupus, vasculitis, drug safety and orthopedics.

And in those pods, two hour sessions, you're gonna have two or three half hour lectures and you're gonna end it with a half hour panel discussion. They'll be moderated and we're gonna take questions from the apps, questions from the audience, questions from people viewing in from the outside. This is a highly digital meeting, there's digital downloads, there's crosstalk, there's again, a lot of facets to this that you've never seen before that'll make this a really unique and interactive experience. I think you'll be excited by what we're going to produce. You can go to roomnow.live to read more about this and to register.

It's gonna be sixteen plus hours of CME, and a fabulous faculty that I'll tell you more about in subsequent weeks. But first, what about the news this week? Should you be monitoring immunoglobulins in patients on rituximab? What really is the best test for carpal tunnel syndrome? And did you know that the first rheumatologists were in fact the three wise men who visited the baby Jesus?

More on that. So we'll begin with a literature review that talks about dactylitis and what works well. A systemic review of the literature came up with the following that the drugs that seem to work very well in dactylitis include ustekinumab, the IL-seventeen inhibitors ixekizumab and secukinumab, adalimumab and apimelast, meaning that there's good evidence from those clinical trials that those work. Working, almost as well would include clazikizumab, abatacep, and tofacitinib. Not so good, the other IL-seventeen inhibitor bredalumab, but that did have trouble with other trials as well.

What about lupus and pregnancy? An interesting abstract was presented at ACR about a month ago now from Bella Metta from HSS, and she actually looked at the National Inpatient Database, over a sixteen year period looking at seven thousand lupus pregnancies and a match cohort and found not surprisingly but now good data for a higher rate of the following in lupus patients, higher rates of C sections, higher rates of intrauterine fetal death, preeclampsia, eclampsia, venous thromboembolic events, chronic kidney disease, hypertension and longer hospital stays. A lot of these actually did improve over time as lupus care improved over time. But those are the data and suggests what the challenge really is in lupus. So carpal tunnel syndrome, we all do what?

Thump, thump, thump, the tunnel sign or the Phelan sign. Well, it turns out that those don't perform very well. A recent analysis of over 500 patients who are tested in all kinds of ways for the diagnosis of proven carpal tunnel syndrome says that actually the best thing is probably the Durkin test. It turns out that, the Tinel's sign really was very poorly sensitive and not very specific. The most specific was thenar atrophy and the Durkin sign.

What is the Durkin's test? The Durkin's test is when you take both thumbs and put it over the median nerve and squeeze. And then the induction of either pain and or numbness in the distribution of the median nerve within thirty seconds is a positive Durkin's test. That seemed to actually be the best test to diagnose carpal tunnel syndrome. So again, the numbers actually were, I have it here, theater atrophy and sensory loss were the most specific and theater actually had the lowest sensitivity though.

It's not seen very often, but when you have theater actually not so good. Again, Tinel sign the lowest specificity of 40% and the lowest negative predictive value. An interesting study looked at Behcet syndrome and this comes from, again, Korea and in Southeast Asia, they have more Behcet, and maybe it's different than what we see in The United States. But I was intrigued by some of the numbers here and the numbers were low. But basically, is the data they looked at the end of the risk of cancer in patients with Behcet's, and they found somewhere between twenty four and thirty four fold higher rate of hematologic malignancy, especially myelodysplasia and leukemia versus the general population, and an overall higher rate of cancer in women with Behcet's disease, and colon involvement compared to men.

Now, again, the issue there is looking at Behcet's disease with colon involvement specifically, not just sores in the mouth and genital area, with colon involvement, and there's a much higher association. Now we do know that other chronic inflammatory conditions that involve the colon are also associated with risk of cancer, so it's not surprising, although the numbers are low here and they actually if you do literature search, you'll see this kind of data out there, that may be something we should think about in our patients, outside of Japan and Korea. So I know this is not rheumatology, but I think it's great because we tell our patients things because things we were told to tell them, including if you have heart failure, low salt diet. Again, a big meta analysis in JAMA showed this week that there's limited evidence, really no evidence showing that the benefit of reducing dietary salt in the control and management of heart failure patients. Again, this speaks to being careful about the data and knowing the data when talking to patients and giving advice about how to avoid disease.

Really shocking data, I know that you're kind of sick of hearing about opioid crises and opioid overdose deaths, but again, a recent DEA report is another head slapper. Twenty seventeen, seventy two thousand opioid related overdose deaths. And do the math, that's about two hundred deaths per day, Just shocking and it's led by heroin, fentanyl, other opioids, methamphetamines, and again, and cocaine is in there, but there's also a lot of adulterated fentanyl and a lot of adulterated drugs in there that are causing the problem. A very interesting study comes from Haiyuan Choi and his colleagues in, the partners database out of the Harvard hospitals, and they looked at the value of immunoglobulins in monitoring for rituximab toxicity. Specifically, looked at about somewhere less than five thousand patients in the PARTNER's database and showed first that eighty five percent had no monitoring of immunoglobulin at all.

I'm guilty, I must say that I don't do that. When you ask rheumatologists, and you're not supposed to do it per the package insert, the package insert says monitor for infection risk, monitor for cytopenias. They don't say anything about looking at immunoglobulin levels, but it does say that low immunoglobulins may portend the risk of infection. So again, should we worry about this or not? Turns out that the rheumatologists who do regular monitoring of immunoglobulins tend to be the allergy, immunology rheumatologists, Artie Kavanaugh, Bing Bingam, they really think it's good idea and you got to listen to smart guys like that.

But what's the data? Well, it turns out that again, while immunoglobulin levels aren't changed all that much by and certainly rheumatoid factor and CCP early on are not changed all that much by giving rituximab over time it does appear that those will drop. In their data set, they found out of the fifteen percent who actually did immunoglobulin levels, they did find in almost half the patients hypogammaglobulinemia after taking rituximab and in that scenario, there was a higher risk of infection. What is the data here and is there more to this? Well, we did report on this before Ron Van Vollenhoven's, cumulative study of the clinical trials with rituximab in RA basically showing that when you monitor, there doesn't seem to be any value to finding low IgM values, which is seen in about a quarter of the patients.

But that IgG values being below the lower limits of normal was found both prior to giving rituximab and after rituximab. In either instance, it was associated with a significant increased risk of SIE serious infectious events. Without knowing that data, the overall rate was around three and a half per one hundred patient years serious infections, but that when you are hypogammaglobulinemic for IgG, again, only four percent, that there was a significant doubling almost eight percent risk of an SIE. Should you be doing it? Well, that's the data.

Again, there's no clear guideline. I think it may be wise to get pre treatment and post treatment IgG levels to know what to do going forward. They did show in the Boston dataset was that for those individuals who went on to receive supplemental gamma globulin, they also showed that significantly reduced the rate of infections that ensued. Important to know. What about nonsteroidals?

Interesting data about nonsteroidals, and the risk of side effects, especially in high risk patients. Now we all know the risk of nonsteroidals and this particular study is a little bit slanted, little unique. It's a two different large claims data from Canada looking at over, you know, a half million primary care visits and, a total of eight hundred thousand plus patients, older patients who also had either hypertension, heart failure or chronic kidney disease. And they found that ten percent of these were prescribed nonsteroidal, eighty plus thousand people who maybe shouldn't be getting nonsteroidals were getting nonsteroidals. And in their match cohort analysis of thirty five thousand who were on nonsteroidals, who had these comorbidities and then compared to those who were not exposed to nonsteroidals, they actually showed in the short term between seven and thirty five days of follow-up, there was no increased rates of cardiac complications, less than one percent, renal complications, zero point one percent for both, and death zero point one percent for both suggesting that in the short term, nocerebral use may not be that hazardous.

Now they may be looking at the wrong outcomes here, right? It may be that they should be looking at longer term outcomes, and we certainly know that that's going to be the case if you follow them long enough. But if you're intending only to use them for short term use, like in the case of gout, where you might use them for short term use, maybe that's okay. A real big brouhaha in the literature and the news this week is the FDA's, decision to approve the new super opioid called DSUVIA, D S U V I A. This is sufentanil, it's a sublingual tablet, it was approved on November 2, indicated for the use of acute pain management in that severe enough to require opioid analgesic use in adults in certified medically supervised healthcare settings.

Are you kidding me? Did you just hear about the data we talked about two hundred deaths a day due to opioids and now the FDA is approving another one? Here's the real slap a head slapper that this drug is five to 10 times stronger than fentanyl and up to a thousand times stronger than morphine. And the FDA Commissioner Scott Gottlieb came out with a big position paper on defending this saying that again, are instances where patients may not be able to swallow a pill, as a sublingual pill, or may not have IV access, and they were working with the Department of Defense for battlefield use of this kind of medicine. I don't think this is going to be used too much on the battlefield as much as going to be used on the battlefield of being inner city places and people who want to abuse a drug.

That's the big concern here, big pushback from a lot of people. I'll end with a discussion of three wise men and why they're likely to be rheumatologists. Came and again, they visited the baby Jesus, think around Christmas Eve, that's what I'm told. They came bearing what? Gold, the rheumatologist's best drug prior to methotrexate, frankincense and myrrh.

What the heck are those anyway? Turns out that myrrh is often an ingredient, it's a fragrance, it's often an ingredient included toothpaste and dental products and whatnot. Again, the perfect drug for those who have periodontal disease, which as we know is a significant risk factor for rheumatoid arthritis. And frankincense, guess what frankincense is derived from the Boswellia plants. Boswellia has actually got three or four different kinds of plants and one of the most, common extracts of that is Boswellia serrata.

It's an Ayurvedic medicine that's purported to have these anti inflammatory properties. If you look it up, there's a number of pilot trials showing it does seem to work in osteoarthritis, and probably not before it's anti inflammatory, but maybe pain relieving properties. It does in experimental situations inhibit five lipoxygenase and maybe prostaglandins. Again, rheumatologists go Frankincense and myrrh, there we were and where we've been ever since. I'll end with the advice, what is a great doctor?

Again, we've talked about this before. In listening to patients recently, I came to the conclusion a great doctor is someone who either cares and also shows their personality. Being dispassionate, know it all, do what I say doesn't seem to work. That's it for this week. Go to the website to get these links and more.

Bye.