The RWCS - RheumNow Week In Review - 9 February 2018 Save
The RWCS - RheumNow Week In Review - 9 February 2018 by Dr. Cush
Transcription
It's 02/09/2018. This is the Room Now Weekend Review. Hi, I'm Doctor. Jack Cush, Executive Editor of roomnow.com, and this is the Week In Review. This week in the news, we have highlights from the twenty eighteen RWCS meeting in Maui.
A lot of good presentations to hear about. We also have information about nail fold capillary dropout predicting what may happen in scleroderma. We also have data about uveitis and how often that happens predicting what happens in patients who have ankylosing spondylitis. And lastly, and sadly, there's bad news. There's not enough rheumatologists.
Top of the news, we have two reports that were presented by Alvin Wells and Orrin Traum at yesterday's meeting about uricase directed therapies. One is a story of pegciticase linked to rapamycin. The molecule is called SEL-two 12, and there was a phase two study presented at ACR that detailed its effect in a cohort of tophaceous gout patients. It met its endpoint by significantly lowering uric acid to a very low and undetectable levels, but was also effective. They had a very low flare rate of twenty two percent.
They only had two infusion reactions amongst the twenty two patients that were treated. It was overall a success in the study. And it turns out that now this is going to be the fuel to go forward and do a much larger phase III study. So one of the problems, as they saw, what they perceived was that if you don't suppress the immune response to uricase, then you're going to get a lot of reactions, infusion reactions. That's why they use this nanoparticle rapamycin linked to the pegciticase.
Another report that was also presented at ACR was called the triple study that featured peglodecase. Peglodecase, as you know, is a pegylated uricase that is also used and now indicated for patients with chronic refractory gout. In this particular study, they actually tried to show whether or not you could induce tolerance by giving the infusions more frequently. So what they did was they gave three weekly infusions as opposed to every other week. They gave three weekly infusions for the first three infusions and then went into the usual therapy.
In this trial, they showed it was again efficacious, that they think they were able to show some degree of high zone tolerance, and it becomes, again, more data to go forward to find better ways and safer ways in which you can actually infuse KRYSTEXXA or pegilodecase. A biosimilar study was also reviewed by one of the faculty. This is the DAM bio study, where it was mandated that patients had to switch from the old, infliximab to the new biosimilar infliximab. And in this particular study, what was interesting was that they just looked at, they know it worked, there was evidence that there was going to be a reasonable transition as far as efficacy and whatnot, but they looked at whether or not the patient's perceptions of the therapy was going to change, and they measured that by looking at patient, interactions with the clinic, both in the preceding months before the switch and the months after the switch. And they showed really no difference and used that as a surrogate measure to say that, you know what?
Patients seem to do well even when they're forced to switch their biosimilar to the, switch to a new biosimilar. Doctor. Bevra Han, who's the kahuna, which means teacher in Hawaiian, she's the big kahuna at this meeting. She gave her first presentation, two days ago on cardiovascular disease and lupus and looking at a number of different factors that may influence that. In one of her, points from her presentation was the things that usually predispose to cardiovascular disease in lupus are the following: prednisone dose greater than twenty milligrams per day, high disease activity as measured by the usual measures, including high double stranded DNA, low complement levels, a high CRP, and plus the usual predictors of cardiovascular disease, hypertension, diabetes, age, being male, hyperlipidemia, etcetera.
So a nice presentation. Listen to, our podcast to hear more about her presentation. We reviewed some data about exercise and rheumatoid arthritis. In one particular trial, the protocol was to take a large cohort of patients and instruct them on increasing their daily exercise. The goal was to meet a standard of moderate to severe exercise as, measured as either a hundred and fifty minutes per week, then it would be moderate exercise, vigorous exercise being seventy five minutes per week of vigorous exercise, more strenuous, etcetera.
And that was the goal. And it turns out that, when they did that, they certainly improved their outcomes, including HACS scores. But what was very clear from that study was that it was the patients who had low disease activity who showed a stepwise increase in their, outcomes and in their HAC scores, when they increased their exercise. However, those who had high disease activity were not able to do this, suggesting that that's the more challenging population, the population who needs the instruction who can't seem to get there because of their disease activity. We need to be able to prescribe physical exercise for our patients and be smart about it.
We need more studies like this. A tweet from this week on the website is OCD. What is it you say? That's right. Osteochondritis, desiccans, something we don't see much of, but we should know about.
It's a condition of young adults, that where they often present with pain catching in the joint. They may, when they present, have effusions, and it's almost always going to be the knee, although the ankles have been described. But it's again, adults, more often males, and they often start out in the orthopedist clinic, but they may end up in yours. It's caused by focal alterations in cartilage and subchondral bone that leads to this defect that often may need surgical intervention. It's often also a radiographic diagnosis.
So be aware in young individuals who presenting with undiagnosed pain and catching and effusion, this could be OCD, osteochondritis desiccans. A patient, study of, of those with ANCA associated vasculitis revealed what may portend the future when looking at their renal function. So a study of one hundred and forty two patients who have glomerulonephritis due to ANCA associated vasculitis were followed prospectively. Almost half of them had both proteinuria and hematuria, but it turns out it wasn't the proteinuria that predicted their future relapse rate. It was actually hematuria.
So it turns out between those two, you should probably be paying more attention to the hematuria than the proteinuria. Again, both are important, but as far as future relapse rate, in this particular study, it was the hematuria that predicted the outcomes. An interesting report comes along about uveitis and ankylosing spondylitis. We all know that patients with ankylosing spondylitis and spondyloarthritis have a forty percent risk of developing acute anterior uveitis. In this particular cohort based study, what they did was they looked at, a large segment of, of the population who had new onset of acute anterior uveitis and then followed them prospectively.
It turns out, and they compared them to those, a population that was matched that did not have uveitis. And it turns out that if you had the first episode of acute anterior uveitis, you ultimately had a sevenfold higher risk of developing ankylosing spondylitis. On the other hand, if you went on to have a second episode or recurrent uveitis, you had an even higher rate, a seventeen fold higher chance of getting ankylosing spondylitis. So again, there seems to be a bilateral relationship that spondyloarthropathy relates to uveitis, but also uveitis, not surprisingly relates to a future risk of ankylosing spondylitis. In the month of January, there were two important studies that looked at nail fold caproloscopy in patients with scleroderma.
One about fifty patients, the other about one hundred and fifty patients, but they both looked at the same thing and came to the same conclusions, that it is dropout of capillaries on nail fold caproloscopy that has a high predictive value in predicting mortality in all scleroderma patients or also when it's looked at in only systemic sclerosis patients. So it is the dropout and the frequency and the degree of dropout that actually predicts mortality, and is way better than autoantibody and other measures that we often might use to predict mortality. It seemed like the only in one study, the only thing that was better might have been progression of skin score, might have been superior to nail fold capillaroscopy, suggesting that we probably should be doing this more frequently in our patients who may have these disorders and certainly in those who do have this disorder. Lastly, we have a saddening report about the future of rheumatology, wherein the ACR has now published its manpower studies. If you were at last year's ACR, you will have seen a slew of reports that had to do with the manpower issue, looked at many, many different ways, and there are two reports in an editorial in the current edition of Arthritis and Rheumatology that looked at this.
Specifically, they show that right now where we stand is, as far as the supply and demand, the demand exceeds the supply by 700 providers. So we're already in a deficit. But it's projected that by 2030, which is, we do the math on that, thirteen years from now, we're going to be in a major deficit short by 4,133 providers by 2030, suggesting we need to train more or we need to go to more advanced practice providers. Talking about nurse practitioners and physician assistants. This deficit is really going to be fueled by what's said to be a tsunami of retiring white, older rheumatologists, and we're going be left with a bunch of younger rheumatologists who are going to change in their profile.
They're to be younger. They're going be more female. The males dominate right now, but by 2030, it's going to be almost two thirds females who are practicing, and that's a big problem. Also a big problem is the geographic maldistribution of rheumatologists, where if you look across the country, there's a heavy concentration in the Northeast and the East Coast, and not so much when you start getting to the middle of the country and the Southwest. Specifically, there's twenty percent of our rheumatologists are located in the Northeast, but only, what's the number here, point 9% that are in the Southwest.
So that's sort of shocking and says that we need to address that as we address the manpower issues going forward. That's it for this week on RheumNow. What you need to do this week is go to roomnow.com and look at the podcasts from RWCS. All the presenters are doing lectures and videos of their lectures while they're here, and we're turning those into podcasts, and you can listen to them as the Day one, Day two, Day three, Day four podcasts that are available on roomnow.com, on SoundCloud, on Stitcher, and on iTunes. Listen in to what's happening here in RWCS.
We'll see you next week on roomnow.com.
A lot of good presentations to hear about. We also have information about nail fold capillary dropout predicting what may happen in scleroderma. We also have data about uveitis and how often that happens predicting what happens in patients who have ankylosing spondylitis. And lastly, and sadly, there's bad news. There's not enough rheumatologists.
Top of the news, we have two reports that were presented by Alvin Wells and Orrin Traum at yesterday's meeting about uricase directed therapies. One is a story of pegciticase linked to rapamycin. The molecule is called SEL-two 12, and there was a phase two study presented at ACR that detailed its effect in a cohort of tophaceous gout patients. It met its endpoint by significantly lowering uric acid to a very low and undetectable levels, but was also effective. They had a very low flare rate of twenty two percent.
They only had two infusion reactions amongst the twenty two patients that were treated. It was overall a success in the study. And it turns out that now this is going to be the fuel to go forward and do a much larger phase III study. So one of the problems, as they saw, what they perceived was that if you don't suppress the immune response to uricase, then you're going to get a lot of reactions, infusion reactions. That's why they use this nanoparticle rapamycin linked to the pegciticase.
Another report that was also presented at ACR was called the triple study that featured peglodecase. Peglodecase, as you know, is a pegylated uricase that is also used and now indicated for patients with chronic refractory gout. In this particular study, they actually tried to show whether or not you could induce tolerance by giving the infusions more frequently. So what they did was they gave three weekly infusions as opposed to every other week. They gave three weekly infusions for the first three infusions and then went into the usual therapy.
In this trial, they showed it was again efficacious, that they think they were able to show some degree of high zone tolerance, and it becomes, again, more data to go forward to find better ways and safer ways in which you can actually infuse KRYSTEXXA or pegilodecase. A biosimilar study was also reviewed by one of the faculty. This is the DAM bio study, where it was mandated that patients had to switch from the old, infliximab to the new biosimilar infliximab. And in this particular study, what was interesting was that they just looked at, they know it worked, there was evidence that there was going to be a reasonable transition as far as efficacy and whatnot, but they looked at whether or not the patient's perceptions of the therapy was going to change, and they measured that by looking at patient, interactions with the clinic, both in the preceding months before the switch and the months after the switch. And they showed really no difference and used that as a surrogate measure to say that, you know what?
Patients seem to do well even when they're forced to switch their biosimilar to the, switch to a new biosimilar. Doctor. Bevra Han, who's the kahuna, which means teacher in Hawaiian, she's the big kahuna at this meeting. She gave her first presentation, two days ago on cardiovascular disease and lupus and looking at a number of different factors that may influence that. In one of her, points from her presentation was the things that usually predispose to cardiovascular disease in lupus are the following: prednisone dose greater than twenty milligrams per day, high disease activity as measured by the usual measures, including high double stranded DNA, low complement levels, a high CRP, and plus the usual predictors of cardiovascular disease, hypertension, diabetes, age, being male, hyperlipidemia, etcetera.
So a nice presentation. Listen to, our podcast to hear more about her presentation. We reviewed some data about exercise and rheumatoid arthritis. In one particular trial, the protocol was to take a large cohort of patients and instruct them on increasing their daily exercise. The goal was to meet a standard of moderate to severe exercise as, measured as either a hundred and fifty minutes per week, then it would be moderate exercise, vigorous exercise being seventy five minutes per week of vigorous exercise, more strenuous, etcetera.
And that was the goal. And it turns out that, when they did that, they certainly improved their outcomes, including HACS scores. But what was very clear from that study was that it was the patients who had low disease activity who showed a stepwise increase in their, outcomes and in their HAC scores, when they increased their exercise. However, those who had high disease activity were not able to do this, suggesting that that's the more challenging population, the population who needs the instruction who can't seem to get there because of their disease activity. We need to be able to prescribe physical exercise for our patients and be smart about it.
We need more studies like this. A tweet from this week on the website is OCD. What is it you say? That's right. Osteochondritis, desiccans, something we don't see much of, but we should know about.
It's a condition of young adults, that where they often present with pain catching in the joint. They may, when they present, have effusions, and it's almost always going to be the knee, although the ankles have been described. But it's again, adults, more often males, and they often start out in the orthopedist clinic, but they may end up in yours. It's caused by focal alterations in cartilage and subchondral bone that leads to this defect that often may need surgical intervention. It's often also a radiographic diagnosis.
So be aware in young individuals who presenting with undiagnosed pain and catching and effusion, this could be OCD, osteochondritis desiccans. A patient, study of, of those with ANCA associated vasculitis revealed what may portend the future when looking at their renal function. So a study of one hundred and forty two patients who have glomerulonephritis due to ANCA associated vasculitis were followed prospectively. Almost half of them had both proteinuria and hematuria, but it turns out it wasn't the proteinuria that predicted their future relapse rate. It was actually hematuria.
So it turns out between those two, you should probably be paying more attention to the hematuria than the proteinuria. Again, both are important, but as far as future relapse rate, in this particular study, it was the hematuria that predicted the outcomes. An interesting report comes along about uveitis and ankylosing spondylitis. We all know that patients with ankylosing spondylitis and spondyloarthritis have a forty percent risk of developing acute anterior uveitis. In this particular cohort based study, what they did was they looked at, a large segment of, of the population who had new onset of acute anterior uveitis and then followed them prospectively.
It turns out, and they compared them to those, a population that was matched that did not have uveitis. And it turns out that if you had the first episode of acute anterior uveitis, you ultimately had a sevenfold higher risk of developing ankylosing spondylitis. On the other hand, if you went on to have a second episode or recurrent uveitis, you had an even higher rate, a seventeen fold higher chance of getting ankylosing spondylitis. So again, there seems to be a bilateral relationship that spondyloarthropathy relates to uveitis, but also uveitis, not surprisingly relates to a future risk of ankylosing spondylitis. In the month of January, there were two important studies that looked at nail fold caproloscopy in patients with scleroderma.
One about fifty patients, the other about one hundred and fifty patients, but they both looked at the same thing and came to the same conclusions, that it is dropout of capillaries on nail fold caproloscopy that has a high predictive value in predicting mortality in all scleroderma patients or also when it's looked at in only systemic sclerosis patients. So it is the dropout and the frequency and the degree of dropout that actually predicts mortality, and is way better than autoantibody and other measures that we often might use to predict mortality. It seemed like the only in one study, the only thing that was better might have been progression of skin score, might have been superior to nail fold capillaroscopy, suggesting that we probably should be doing this more frequently in our patients who may have these disorders and certainly in those who do have this disorder. Lastly, we have a saddening report about the future of rheumatology, wherein the ACR has now published its manpower studies. If you were at last year's ACR, you will have seen a slew of reports that had to do with the manpower issue, looked at many, many different ways, and there are two reports in an editorial in the current edition of Arthritis and Rheumatology that looked at this.
Specifically, they show that right now where we stand is, as far as the supply and demand, the demand exceeds the supply by 700 providers. So we're already in a deficit. But it's projected that by 2030, which is, we do the math on that, thirteen years from now, we're going to be in a major deficit short by 4,133 providers by 2030, suggesting we need to train more or we need to go to more advanced practice providers. Talking about nurse practitioners and physician assistants. This deficit is really going to be fueled by what's said to be a tsunami of retiring white, older rheumatologists, and we're going be left with a bunch of younger rheumatologists who are going to change in their profile.
They're to be younger. They're going be more female. The males dominate right now, but by 2030, it's going to be almost two thirds females who are practicing, and that's a big problem. Also a big problem is the geographic maldistribution of rheumatologists, where if you look across the country, there's a heavy concentration in the Northeast and the East Coast, and not so much when you start getting to the middle of the country and the Southwest. Specifically, there's twenty percent of our rheumatologists are located in the Northeast, but only, what's the number here, point 9% that are in the Southwest.
So that's sort of shocking and says that we need to address that as we address the manpower issues going forward. That's it for this week on RheumNow. What you need to do this week is go to roomnow.com and look at the podcasts from RWCS. All the presenters are doing lectures and videos of their lectures while they're here, and we're turning those into podcasts, and you can listen to them as the Day one, Day two, Day three, Day four podcasts that are available on roomnow.com, on SoundCloud, on Stitcher, and on iTunes. Listen in to what's happening here in RWCS.
We'll see you next week on roomnow.com.
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