Weak Data (1.24.2025) Save

This is the RheumNow podcast. Today is 01/24/2025, and I'm Jack Cush with RheumNow. I wanna remind you, RheumNow live is coming up in two weeks. You wanna register as soon as possible so you're not gonna be left out. You know, what happens when you turn on your radio station that, you know, your go to?

You know, what's your go to? Is it the blend? Is it the Tom Petty channel? Is it all Beatles all the time? And what and what happens when I turned on the eighties yesterday, because I thought the eighties were my year for music, and they played, like, nine songs in a row that were like, you know, how does that happen?

Why don't they give me what I want all the time? I fear that today's podcast maybe you might have tuned into the wrong channel, because, you know, there's a lot of interesting stuff that happened this week. You're gonna you're gonna have to judge for yourself. So, Korean, biologics registry called, COBio, good registry, they do good data. They looked at their patients with spondyloarthritis and looked at the frequency of infection and showed, not surprisingly, patients with ankylosing spondylitis spondyloarthritis have a higher risk of infection, especially serious infection.

They studied over almost two thousand one hundred AS patients, followed them for seven 100 patient years. That's either seven thousand patients followed one year or 1,000 patients followed seven years. You figure it out. And the incidence of infection was two point six per one hundred. That was actually higher than their control population.

The next most common By the way, those were respiratory infections. So that would mainly be pneumonia, right? The most common, and goes way down, like seventy five percent down, is herpes zoster at zero point six per one hundred, or six per thousand. Risk factors for infection were, as we talked about before, comorbidities, age, diabetes, heart disease, CKD, having peripheral arthritis as a risk factor. Maybe that's a risk factor for more severe spondylitis.

Anyway, how are going to rank this particular abstract? Get out your ranking cards. Let's rank on a scale of zero to 10. We're going to drop the high and the low and take the average. Yeah, I give this about a six, right?

So, a French study looked at, stable methotrexate patients, with, and who were on methotrexate for many years, and they examined polyglutamate levels and its association with disease activity. It's a small study, already the score is going to be low, it's only thirty four patients, twenty five of whom were in remission. And they showed that there was a good correlation between remission and the higher levels of PG3 polyglutamate levels. But this only applied to patients with a BMI that was normal or less than twenty five. This is yet another reason why I don't do methotrexate polyglutamate levels, because, you know, I think you would do it if you weren't getting the most out of methotrexate, and you wanted to get more, and you had no more no other opportunities.

We now know that from the study and others that, obesity may may get in the way of these ascertainments. What's your score? Yeah, that's a four. Celiac disease and anything gets a two in my book. I don't mean to disrespect celiac disease, except it comes up a whole lot more than the disease actually exists.

Do you agree? So this is a study of RA patients and association with celiac disease, and they looked at like a bazillion patients. Seventy thousand this is like claims data, over eleven, ten year period something. 70,000 RA, almost 300,000 controls, follow-up nine years, and they showed celiac disease had a higher prevalence in RA patients at a prevalence of zero point two four percent. That's two per thousand versus the controls which was one per thousand.

And this was mainly seen in females. Yeah, this stays a two, because it's two per thousand. I mean, I do celiac testing. I'll do antibody testing, which is not totally reliable, and if the patient's concerned about it I'll give them a handout on a gluten free diet, and if they're having, problems I really suspect that I, you know, co manage with GI. But this is really not on my radar ninety eight percent of the time.

Fault me for not putting it on my radar, but that's the way it goes. Another Korean population based study showed that the incidence and prevalence of ankylosing spondylitis increased almost three and a half fold between 2010 and 2023. So I already told you they got thousands of ankylosing spondylitis patients in that CoBio registry. This is not a CoBio registry study, by way. This is a population based study based on, coding, right?

So, the incidence in 2010 was twenty seven per one hundred thousand, went up to eighty two per one hundred thousand in 2023. Is that a shocker? Well, it's a big jump, is it not? In a ten year period or thirteen year period, it goes up 3.5 fold. And what went up was the number of people that were diagnosed after the age of 50.

It went from twenty-thirty three percent. Females eighteen-twenty four percent. Those with comorbidities, the use of TNF inhibitors went up, while DMARD, conventional DMARD, I. E. Methotrexate sulfasalazine went down.

So is this just not greater awareness, better education? Do you really think that the frequency of the disease has had a threefold population increase? I don't think that's the de novo cause. So get out your scorecards. Again, this is maybe, three or four.

But I like putting these kind of things up, if only to get you thinking, if only to argue, to only discuss with your colleagues. You should always be suspect of the next two studies, because they are meta analyses, systematic reviews. And I don't rank those very high, but sometimes when you can't get data, it's the best you got. So this systematic review of claims data on one hundred and thirty million people and a million with dementia found that the risk of dementia in Alzheimer's was reduced by the use of antimicrobials, vaccinations and nonsteroidals. Well, that's why I put it up.

Nonsteroidals. Hey, we rheumatologists, we're preventing dementia. But we rheumatologists are not using nonsteroidals as we once did during my fellowship in the 80s and 90s when that's pretty much all we had. Most of the current fellows are not using much in the way of nonsteroidals. I don't think that they're bad.

I think you have to make sure that you don't use them in people at risk. But here's another side benefit to nonsteroidals, as there is a benefit to the reduction in colon cancer and polyps, right? And a whole bunch of other cancers associated with use of nonsteroidals, especially COX-two inhibitors. So, why antibiotics and vaccines? Well, those are people that are going to the doctor more.

You could say the same thing about nonsteroidals. What was associated with an increased risk of dementia and Alzheimer's? Being on a diabetes drug, taking vitamins and taking antipsychotics. I put this up there because of the nonsteroidals, I put this up there because of a lot of us have people in our lives that worry about Alzheimer's and dementia, and I think it's important to know this kind of data. A Still's disease study done by Ruchetti and colleagues in Italy great group, they do a lot of good Still's research they did a review of their registry and patients that had lung disease with Still's disease, and they affirmed that pleuritis was the most common of the manifestations.

It was, I think, seventy five percent of patients in pleuritis. Other, large population studies with Still's say it's about sixty five percent, seventy percent where it's a presenting or feature once the diagnosis is made. Usually it's a presenting feature. Parenchymal disease, which could be pneumonitis, they had at thirty five percent. And then other things were really really rare, including pulmonary hypertension.

What they commented on here was this association of lung disease in stills, whether it's kids or adults, bad lung disease, and that being associated with the use of IL-one or IL-six inhibitors, or certain HLA haplotypes. Well, they didn't do any genetic studies here. They did not show any association between the lung disease of Still's disease with IL-one or IL-six inhibitor use. So, because I'm an IL-six, an IL-one and Still's disease maven, I'm gonna give this an 11 on a scale of zero to 10, because, you know, this is the kind of stuff that gets me going. A population based study of almost a thousand patients with gout, and they were, as you might expect, in their 50s, three quarters male, mostly white, that the burden of gout flares was six point six flares per year.

We owe oh my goodness. But the real point of this paper was that and this was data taken from patients, right? They were surveying the patients themselves. But seventy two percent of patients said they did not report their flares to the doctor, or that their flares were not being pretreated or prevented with some medicine to prevent flares. Wow, this is yet another area that we should be tackling in gout management.

The ones who are less likely to report, their flares to their doctors or health care providers where they were younger, less education, they had fewer comorbidities. It's kind of as you might expect: young and stupid, you know. Unfortunately, when you're young and you have these diseases, you make all kinds of wrong choices, and that you have to learn the hard way. Or by going to a good rheumatologist who can educate you and make you smarter than stupid. Anyway, a post hoc analysis of gout and pegilodecase was published by Orrin Traum this past week, or this past month.

Using the data from the four registration trials with peglodecase, they showed that rates of major adverse cardiovascular events and thromboembolic events DVTs, VTEs, etc. These were actually quite rare. They were less than one point five percent or only three events per 100 patient years. And this was similar to other gout patients, right? So, these are patients in the peglodecase trial, presumably really severe gout, compared to the general gout population.

Those MACI events and VTEs were not increased, and I think this is important to know, because many of us are not using peglodecase. Peglodecase is a major advance for major leak, really severe gout. To not use it is a shame. This data and other data has been put out suggest that it is safe and you should be considering it. Medicare, came out with a new announcement.

As you remember last year, under the Biden administration, they announced that they were going to negotiate, prices of drugs, especially expensive drugs with Medicare. I'm sorry, Medicare was going to negotiate these with the manufacturers, they listed 10 drugs in 2024 that they were going to negotiate going forward, and this included ustekinumab and etanercept as expensive drugs that they needed to negotiate. They came out with another 15 drugs, and yes, our drugs are on the list. This includes nintedinib, also called Ovef for pulmonary hypertension and IPF, aprimolase or Otezla also are going to be negotiated, as are the GLP-one drugs going forward, because they're very much in vogue and it's kind of a hot button issue. I think this is a great advance in how we're going to manage the cost of drugs.

Another VA study was published this week talking about the risk of multiple myeloma in RA patients taking either biologics or targeted synthetics, and amongst twenty seven thousand patients, thirty percent of whom were taking either one of these advanced therapies, including biologics, there are only seventy seven cases of myeloma and biologics and targeted synthetics were not associated with a risk of myeloma. I'm sure you weren't even aware that it was a possibility. I'm sure you didn't think that this was possible. Am I telling you it's not possible? Is like, why are you wasting my time?

Yeah, you can give this a one if you want, but I like bothering you with, Picayune data. And who knows, maybe this discussion is going to come up in Peoria in the next week on rounds? Well, I heard last week that there is no association with myeloma and biologics. It's based on a VA study of twenty seven thousand RA patients. How could you, my mentor, be arguing with me about this?

These are the facts. Stay up to date, dude. That's why I report this stuff. Inflammatory arthritis and depression, we've talked about it before, and there's a report this week from Canada looking at almost seven thousand patients with inflammatory arthritis showing that only I'm sorry, seven thousand patients with inflammatory arthritis and depression. And then there were three thousand patients with inflammatory arthritis and anxiety.

And both of these populations were vastly undertreated, for any kind of treatment for their depression or anxiety, or specific treatment for their depression and anxiety. Again, I strongly urge you to ask the question: do you have depression? Is depression an issue? Do a PHQ-nine survey. Use my RoomNow survey or Ted Pincus's MD Hackett asks about those things.

We're gonna end with getting to remission without biologics. This is an article that I saw in Healio, by the way, that the same day it came out, and I put it up on RheumNow at the same time. And, it's a report at a Lancet, Rheumatology, and, it's a cohort study of a thousand patients with early rheumatoid arthritis. And the investigators who run these early rheumatoid arthritis clinic, the EAC out of Leeds, run by Paul Emery, and the T REACH study out of Rotterdam, that's another early arthritis study. These investigators have must have had a conversation, over a pint, about, you know, we don't, see remission in people that go on biologics.

Or they saw the converse, which is what they say in this paper, is that if you didn't need biologics with RA, you had a much better chance of getting to remission. So, six hundred patients with early arthritis out of Leeds, fourteen percent were on biologic, eighty six percent were not. The people on biologic none were in remission. Thirty seven percent who were not on a biologic, right, actually achieved remission. Gigantic difference here.

The same was seen with the and that's a five year outcome study. A three year outcome study from T REACH in Rotterdam, four twenty five patients, they had thirty six percent who had been on a biologic and zero percent of them were in remission at three years. And of the ones who did not receive a biologic, fifteen percent, went on to achieve remission. So, this is either a brilliant study or a duh. What are you thinking?

Of course, if you don't need biologics, well, you're not that bad and you've probably got a better chance of getting to remission. But I also like the idea that this designation, of whether you receive the biologic or not, is pretty much up to you. You make that decision, right? It doesn't require expensive tests or, you know, doing 10 finger calculations to get to a gas score, c die score, s die, whatever you like to do, in a rapid three. I think that you can tell when someone has good disease, you can you should be expecting remission or striving for remission.

Maybe if they have difficult disease and they need to be on a biologic or combination of drugs, know it's going to be harder. And maybe you'll never get to remission, but you can certainly get to low disease activity state. I like that one. I'm going to give that one an eight. You might give it a six.

Bring your scorecard next week, we can see if we can do better. Room now live, February eighth and ninth. I want to talk about the keynote speaker, doctor Charity Dean. I learned about doctor Charity Dean by watching a master class on writing by the famed author Michael Lewis. Michael Lewis wrote many famous books.

I think he's written 20 books, but including Liars Poker was his first book. But The Big Short became a movie. The Blind Side with Sandra Bullock became a movie. My favorite movie Moneyball became a movie. He writes great stuff.

He wrote a book during COVID called Premonition. He tells a story about Doctor. Charity Dean, who after her residency became like the county health commissioner for Santa Barbara County. And one of the first things that she encountered was a report of TB. Santa Barbara is a very rich county, but also a very poor county with a lot of migrant workers.

So TB is a problem over there. And in seeing this report she asked the question: Does this person have pulmonary TB? Because if it does she's got a problem and has to look at spread. They didn't know. So it was a case of TB meningitis.

So she said we got to find out, let's exhume the body. So the story that he tells is she calls the medical examiner who's like an old crusty guy with a cigar like Quincy and says Lady, I'm not exhuming the body to find out if it's got TB. You're out of your mind. And he hangs up. She reminds him that she's his superior and he still hangs up.

She calls the chief of police. Chief of police says I'm not going to tell the Emmy what to do. I shoot pool with that guy. Lady, you're out of your mind. Well, she calls the governor and the governor tells the chief of police to tell the other guy, Exhume the body and get it done.

That's what happens. They exhume the body. But they're reluctant. They don't want to do it. They don't like this young whippersnapper woman who's telling them what to do, and who does she think she is.

So on the day that they're going to do the autopsy, it's around Christmas. She's in her car, she's got a sweater on, a holiday sweater, and jeans, and flats on, and she's at a party, and she's going to go by and check out the, the autopsy. She pulls up to this little brick, cement building, one story, and there are five men outside in hazmat suits. And on the dirt ground there's a picnic table, and on the picnic table is a body bag, and the men in hazmat suits are doing nothing. And so she goes over and says, what's going on?

When you do when's the autopsy? And we're not doing it, says the ME. We're we're just not gonna do it. She points to the chief of police. Tell him to do it.

I I can't do that. She's mad. She's really mad. She says, fine, I'll do it. Give me the saw.

I didn't bring the saw to crack the chest, but here are some garden snips from Home Depot. You can get the lung that way. So she goes over the body. She struggles a little bit, she snips snips a few ribs, and the, you know, the men in hazmat suits are there gaping, their mouths are wide open hitting the floor, they can't believe this this young whippersnapper blonde woman is doing this, and she reaches in the lung, in the chest chest cavity. She pulls out a soggy mess, a deflated lung.

She says, give me a bio a specimen bag. They don't have one. She reaches over and grabs the orange Home Depot bucket, throws it in there, walks away, puts the bucket in her trunk and drives away. As soon as I heard that story from Michael Lewis, I went and read the book on Premonition. It's a pretty good book, tells you a lot of things you didn't know about COVID, but this is an interesting person who's got a lot to say about doing it right in medicine, and that's why she's our keynote speaker on Saturday at 4PM, February 8.

Be that room now. I'm gonna be.