CCR 18

SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.

The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.

The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.

“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.

Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.

The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.

SOURCE: Pagnoux C. CCR 2018.

SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.

The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.

The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.

“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.

Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.

The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.

SOURCE: Pagnoux C. CCR 2018.

SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.

The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.

The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.

“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.

Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.

The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.

SOURCE: Pagnoux C. CCR 2018.

SANDESTIN, FLA. – Don’t be a slave to imaging when evaluating the patient with sarcoidosis.

“Sometimes, the worst-looking patients [on imaging] have the best prognosis,” Daniel Culver, DO, said at the annual Congress of Clinical Rheumatology. Patients with Löfgren’s syndrome are a very good example of this tenet, he said in an interview. Scans can look alarming, with multiple widespread granulomas. But Löfgren’s is generally a benign condition, despite its threatening mien.

Instead of imaging, “Let two things drive your decision to treat: danger to an organ, and quality of life,” said Dr. Culver, a pulmonologist and director of the Sarcoidosis Center of Excellence at the Cleveland Clinic in Ohio; he is also president of the World Association for Sarcoidosis.

He agrees with a decision schema published in 2015 (Clin Chest Med. 2015;36[4]:751-67).

Six factors weigh in favor of treatment:

• Symptomatic disease.
• Impaired organ function.
• Disease endangering an organ.
• Progressive disease.
• Clear-cut disease activity.
• Low likelihood of remission.

These must be balanced – with patient input as the fulcrum – against five factors that favor conservative management:

• Minimal symptoms.
• Good organ function.
• Low risk of danger to organs.
• Inactive disease.
• Higher likelihood of remission.

The decision to embark on a treatment program, usually starting with a steroid-based regimen, can’t be taken lightly, Dr. Culver said. A 2017 study showed that steroids pose a cumulative risk of toxicities for sarcoidosis patients (Respir Med. 2017 Nov;132:9-14). Patients who started steroids faced more than a doubling in the risk of a toxic side effect by 96 months when compared with those who didn’t. But even short-term steroid use increased the risk of a toxicity, Dr. Culver said. The study noted that problems can begin to occur in as little as 1 month, at a cumulative dose as low as 1 g.

[email protected]

SOURCE: Culver D. CCR 2018.

SANDESTIN, FLA. – Don’t be a slave to imaging when evaluating the patient with sarcoidosis.

“Sometimes, the worst-looking patients [on imaging] have the best prognosis,” Daniel Culver, DO, said at the annual Congress of Clinical Rheumatology. Patients with Löfgren’s syndrome are a very good example of this tenet, he said in an interview. Scans can look alarming, with multiple widespread granulomas. But Löfgren’s is generally a benign condition, despite its threatening mien.

Instead of imaging, “Let two things drive your decision to treat: danger to an organ, and quality of life,” said Dr. Culver, a pulmonologist and director of the Sarcoidosis Center of Excellence at the Cleveland Clinic in Ohio; he is also president of the World Association for Sarcoidosis.

He agrees with a decision schema published in 2015 (Clin Chest Med. 2015;36[4]:751-67).

Six factors weigh in favor of treatment:

• Symptomatic disease.
• Impaired organ function.
• Disease endangering an organ.
• Progressive disease.
• Clear-cut disease activity.
• Low likelihood of remission.

These must be balanced – with patient input as the fulcrum – against five factors that favor conservative management:

• Minimal symptoms.
• Good organ function.
• Low risk of danger to organs.
• Inactive disease.
• Higher likelihood of remission.

The decision to embark on a treatment program, usually starting with a steroid-based regimen, can’t be taken lightly, Dr. Culver said. A 2017 study showed that steroids pose a cumulative risk of toxicities for sarcoidosis patients (Respir Med. 2017 Nov;132:9-14). Patients who started steroids faced more than a doubling in the risk of a toxic side effect by 96 months when compared with those who didn’t. But even short-term steroid use increased the risk of a toxicity, Dr. Culver said. The study noted that problems can begin to occur in as little as 1 month, at a cumulative dose as low as 1 g.

[email protected]

SOURCE: Culver D. CCR 2018.

SANDESTIN, FLA. – Don’t be a slave to imaging when evaluating the patient with sarcoidosis.

“Sometimes, the worst-looking patients [on imaging] have the best prognosis,” Daniel Culver, DO, said at the annual Congress of Clinical Rheumatology. Patients with Löfgren’s syndrome are a very good example of this tenet, he said in an interview. Scans can look alarming, with multiple widespread granulomas. But Löfgren’s is generally a benign condition, despite its threatening mien.

Instead of imaging, “Let two things drive your decision to treat: danger to an organ, and quality of life,” said Dr. Culver, a pulmonologist and director of the Sarcoidosis Center of Excellence at the Cleveland Clinic in Ohio; he is also president of the World Association for Sarcoidosis.

He agrees with a decision schema published in 2015 (Clin Chest Med. 2015;36[4]:751-67).

Six factors weigh in favor of treatment:

• Symptomatic disease.
• Impaired organ function.
• Disease endangering an organ.
• Progressive disease.
• Clear-cut disease activity.
• Low likelihood of remission.

These must be balanced – with patient input as the fulcrum – against five factors that favor conservative management:

• Minimal symptoms.
• Good organ function.
• Low risk of danger to organs.
• Inactive disease.
• Higher likelihood of remission.

The decision to embark on a treatment program, usually starting with a steroid-based regimen, can’t be taken lightly, Dr. Culver said. A 2017 study showed that steroids pose a cumulative risk of toxicities for sarcoidosis patients (Respir Med. 2017 Nov;132:9-14). Patients who started steroids faced more than a doubling in the risk of a toxic side effect by 96 months when compared with those who didn’t. But even short-term steroid use increased the risk of a toxicity, Dr. Culver said. The study noted that problems can begin to occur in as little as 1 month, at a cumulative dose as low as 1 g.

[email protected]

SOURCE: Culver D. CCR 2018.

SANDESTIN, FLA. – Lyme disease is spreading in the United States, which makes it a high priority for rheumatologists, who will need to care for an increasing number of patients with posttreatment disorders affecting the joints, an expert said at the annual Congress of Clinical Rheumatology.

Sheila Arvikar, MD, an instructor in the rheumatology division at Harvard Medical School, Boston, said that the disease – the most common vector-borne illness in the United States – is no longer strictly confined to the U.S. Northeast and the upper Midwest, according to reports from the Centers for Disease Control and Prevention. Neighboring areas are increasingly affected, the reports have shown.

That the disease may be spreading makes the need for awareness and better testing more acute, she said. Current testing is limited by a lack of sensitivity in early disease, and the standard two-tier combination of enzyme-linked immunosorbent assay and Western blot can be time consuming. But recent studies have found that whole cell sonicate ELISA combined with an ELISA for peptide C6 are equally or even more effective than the more cumbersome, two-tier version, Dr. Arvikar said.

A problem encountered by rheumatologists are patients who contracted Lyme disease but who continue to have joint pain and other symptoms despite treatment for the disease. This so-called posttreatment Lyme disease syndrome (PTLDS) can be similar to fibromyalgia or chronic fatigue syndrome, involving chronic symptoms but no chronic infection and no objective synovitis or inflammation.

There are no Food and Drug Administration–approved treatments for it, but options such as tricyclics, serotonin norepinephrine reuptake inhibitors, gabapentin, and pregabalin can be helpful, she said, along with exercise and cognitive-behavioral therapy. She also noted myriad alternative treatments marketed for PTLDS that have not been shown to be effective and can even be harmful, such as urine ingestion and treatment with bee venom.

“These patients are really desperate for anything to help with their symptoms, and there are lot of people out there who are preying on them with these therapies that aren’t really helpful. It’s important for us to be aware that these things are out there.”

Dr. Arvikar reported having no financial disclosures.

SOURCE: Arvikar S, CCR 2018.

SANDESTIN, FLA. – Lyme disease is spreading in the United States, which makes it a high priority for rheumatologists, who will need to care for an increasing number of patients with posttreatment disorders affecting the joints, an expert said at the annual Congress of Clinical Rheumatology.

Sheila Arvikar, MD, an instructor in the rheumatology division at Harvard Medical School, Boston, said that the disease – the most common vector-borne illness in the United States – is no longer strictly confined to the U.S. Northeast and the upper Midwest, according to reports from the Centers for Disease Control and Prevention. Neighboring areas are increasingly affected, the reports have shown.

That the disease may be spreading makes the need for awareness and better testing more acute, she said. Current testing is limited by a lack of sensitivity in early disease, and the standard two-tier combination of enzyme-linked immunosorbent assay and Western blot can be time consuming. But recent studies have found that whole cell sonicate ELISA combined with an ELISA for peptide C6 are equally or even more effective than the more cumbersome, two-tier version, Dr. Arvikar said.

A problem encountered by rheumatologists are patients who contracted Lyme disease but who continue to have joint pain and other symptoms despite treatment for the disease. This so-called posttreatment Lyme disease syndrome (PTLDS) can be similar to fibromyalgia or chronic fatigue syndrome, involving chronic symptoms but no chronic infection and no objective synovitis or inflammation.

There are no Food and Drug Administration–approved treatments for it, but options such as tricyclics, serotonin norepinephrine reuptake inhibitors, gabapentin, and pregabalin can be helpful, she said, along with exercise and cognitive-behavioral therapy. She also noted myriad alternative treatments marketed for PTLDS that have not been shown to be effective and can even be harmful, such as urine ingestion and treatment with bee venom.

“These patients are really desperate for anything to help with their symptoms, and there are lot of people out there who are preying on them with these therapies that aren’t really helpful. It’s important for us to be aware that these things are out there.”

Dr. Arvikar reported having no financial disclosures.

SOURCE: Arvikar S, CCR 2018.

SANDESTIN, FLA. – Lyme disease is spreading in the United States, which makes it a high priority for rheumatologists, who will need to care for an increasing number of patients with posttreatment disorders affecting the joints, an expert said at the annual Congress of Clinical Rheumatology.

Sheila Arvikar, MD, an instructor in the rheumatology division at Harvard Medical School, Boston, said that the disease – the most common vector-borne illness in the United States – is no longer strictly confined to the U.S. Northeast and the upper Midwest, according to reports from the Centers for Disease Control and Prevention. Neighboring areas are increasingly affected, the reports have shown.

That the disease may be spreading makes the need for awareness and better testing more acute, she said. Current testing is limited by a lack of sensitivity in early disease, and the standard two-tier combination of enzyme-linked immunosorbent assay and Western blot can be time consuming. But recent studies have found that whole cell sonicate ELISA combined with an ELISA for peptide C6 are equally or even more effective than the more cumbersome, two-tier version, Dr. Arvikar said.

A problem encountered by rheumatologists are patients who contracted Lyme disease but who continue to have joint pain and other symptoms despite treatment for the disease. This so-called posttreatment Lyme disease syndrome (PTLDS) can be similar to fibromyalgia or chronic fatigue syndrome, involving chronic symptoms but no chronic infection and no objective synovitis or inflammation.

There are no Food and Drug Administration–approved treatments for it, but options such as tricyclics, serotonin norepinephrine reuptake inhibitors, gabapentin, and pregabalin can be helpful, she said, along with exercise and cognitive-behavioral therapy. She also noted myriad alternative treatments marketed for PTLDS that have not been shown to be effective and can even be harmful, such as urine ingestion and treatment with bee venom.

“These patients are really desperate for anything to help with their symptoms, and there are lot of people out there who are preying on them with these therapies that aren’t really helpful. It’s important for us to be aware that these things are out there.”

Dr. Arvikar reported having no financial disclosures.

SOURCE: Arvikar S, CCR 2018.

SANDESTIN, FLA. – Big data informing patient treatment, computer algorithms reading imaging instead of humans, and even accurate patient self-diagnosis could emerge over the next 10 years in the treatment of rheumatoid arthritis, an expert said at the annual Congress of Clinical Rheumatology.

Gerd Burmester, MD, director of rheumatology and clinical immunology at Charité University in Berlin, trotted out staggering numbers on future medical data collection on patients. Data analytics companies project that more than 1,000 terabytes of data per lifetime is expected to be gathered, with just 10% expected to be clinical information and 30% in the form of “-omics,” such as proteomics and genomics, he said. The other 60% is expected to come from sensors and wearables that patients essentially collect themselves with their own devices, he said.

“We will have to use data in the interest of the patient,” he said. “This is the real secret. In order to do this, we need cognitive computing, which assesses structured and unstructured data and is self-learning.”

The days of images being read by human radiologists could be numbered, he said.

“There will be a revolution in imaging scoring,” he said, with computer algorithms generating scores, more quickly separating the normal scans from those that need clinical attention.

He described a possible scenario in which patients get genetic analyses, blood biomarker testing, and imaging performed at kiosks about town, producing a diagnosis without a single physician visit. It might seem fanciful, but when he asked the audience how many thought it was impossible over the next decade, no one raised a hand.

With advances such as the self-rheumatoid arthritis examination tool Rheuma-Check and the decline in cost for whole genome sequencing – along with wait times to see rheumatologists sometimes as long as 6 months – such a scenario might not be far fetched, Dr. Burmester said. It is possible, he said, because patient histories that used to sit in charts, images that used to be on film only, and genetic data that used to be unavailable, are all now in structured, digital form.

Referring to a recent commentary in the New England Journal of Medicine, Dr. Burmester said physicians have to accept the coming role of computer algorithms.

“If medicine wishes to stay in control of its own future,” he said, “physicians will not only have to embrace algorithms, they will also have to excel at developing and evaluating them, bringing machine-learning methods into the medical domain.”

SOURCE: Burmester, G. CCR 2018.

SANDESTIN, FLA. – Big data informing patient treatment, computer algorithms reading imaging instead of humans, and even accurate patient self-diagnosis could emerge over the next 10 years in the treatment of rheumatoid arthritis, an expert said at the annual Congress of Clinical Rheumatology.

Gerd Burmester, MD, director of rheumatology and clinical immunology at Charité University in Berlin, trotted out staggering numbers on future medical data collection on patients. Data analytics companies project that more than 1,000 terabytes of data per lifetime is expected to be gathered, with just 10% expected to be clinical information and 30% in the form of “-omics,” such as proteomics and genomics, he said. The other 60% is expected to come from sensors and wearables that patients essentially collect themselves with their own devices, he said.

“We will have to use data in the interest of the patient,” he said. “This is the real secret. In order to do this, we need cognitive computing, which assesses structured and unstructured data and is self-learning.”

The days of images being read by human radiologists could be numbered, he said.

“There will be a revolution in imaging scoring,” he said, with computer algorithms generating scores, more quickly separating the normal scans from those that need clinical attention.

He described a possible scenario in which patients get genetic analyses, blood biomarker testing, and imaging performed at kiosks about town, producing a diagnosis without a single physician visit. It might seem fanciful, but when he asked the audience how many thought it was impossible over the next decade, no one raised a hand.

With advances such as the self-rheumatoid arthritis examination tool Rheuma-Check and the decline in cost for whole genome sequencing – along with wait times to see rheumatologists sometimes as long as 6 months – such a scenario might not be far fetched, Dr. Burmester said. It is possible, he said, because patient histories that used to sit in charts, images that used to be on film only, and genetic data that used to be unavailable, are all now in structured, digital form.

Referring to a recent commentary in the New England Journal of Medicine, Dr. Burmester said physicians have to accept the coming role of computer algorithms.

“If medicine wishes to stay in control of its own future,” he said, “physicians will not only have to embrace algorithms, they will also have to excel at developing and evaluating them, bringing machine-learning methods into the medical domain.”

SOURCE: Burmester, G. CCR 2018.

SANDESTIN, FLA. – Big data informing patient treatment, computer algorithms reading imaging instead of humans, and even accurate patient self-diagnosis could emerge over the next 10 years in the treatment of rheumatoid arthritis, an expert said at the annual Congress of Clinical Rheumatology.

Gerd Burmester, MD, director of rheumatology and clinical immunology at Charité University in Berlin, trotted out staggering numbers on future medical data collection on patients. Data analytics companies project that more than 1,000 terabytes of data per lifetime is expected to be gathered, with just 10% expected to be clinical information and 30% in the form of “-omics,” such as proteomics and genomics, he said. The other 60% is expected to come from sensors and wearables that patients essentially collect themselves with their own devices, he said.

“We will have to use data in the interest of the patient,” he said. “This is the real secret. In order to do this, we need cognitive computing, which assesses structured and unstructured data and is self-learning.”

The days of images being read by human radiologists could be numbered, he said.

“There will be a revolution in imaging scoring,” he said, with computer algorithms generating scores, more quickly separating the normal scans from those that need clinical attention.

He described a possible scenario in which patients get genetic analyses, blood biomarker testing, and imaging performed at kiosks about town, producing a diagnosis without a single physician visit. It might seem fanciful, but when he asked the audience how many thought it was impossible over the next decade, no one raised a hand.

With advances such as the self-rheumatoid arthritis examination tool Rheuma-Check and the decline in cost for whole genome sequencing – along with wait times to see rheumatologists sometimes as long as 6 months – such a scenario might not be far fetched, Dr. Burmester said. It is possible, he said, because patient histories that used to sit in charts, images that used to be on film only, and genetic data that used to be unavailable, are all now in structured, digital form.

Referring to a recent commentary in the New England Journal of Medicine, Dr. Burmester said physicians have to accept the coming role of computer algorithms.

“If medicine wishes to stay in control of its own future,” he said, “physicians will not only have to embrace algorithms, they will also have to excel at developing and evaluating them, bringing machine-learning methods into the medical domain.”

SOURCE: Burmester, G. CCR 2018.