ATLANTA—With more than 3,000 abstracts from 103 countries presented at the 2019 ACR/ARP Annual Meeting in November, it was impossible for attendees to view them all. However, two ACR/ARP veterans—Arthur Kavanaugh, MD, from the University of California, San Diego, and John Cush, MD, from UT Southwestern Medical School, Dallas—chose to tackle the nearly impossible task and select the ones they thought were best.
“We would like to reassure everyone that our choices were not influenced by the College, industry or people we shoot pool with,” Dr. Cush said.
Psoriatic Arthritis Prevention
Dr. Kavanaugh’s first choice was a study from Argentina, “Can Biologics ‘Prevent’ the Development of Psoriatic Arthritis in Psoriasis Patients?”
“This study covers a fascinating concept we’ve been thinking about for a while,” Dr. Kavanaugh said. The study’s objective was to analyze the incidence of psoriatic arthritis (PsA) in a large cohort of patients with psoriasis undergoing different treatments, based on the hypothesis that treatment with biologics may prevent the development of PsA.
“To address this,” Dr. Kavanaugh said, “they went into the medical record at the university and found just under 800 patients with skin psoriasis and looked at them according to their treatments; it could be biologic therapy, which was the treatment for about 100 patients, and other conventional DMARD [disease-modifying anti-rheumatic drug] systemic therapies. … After about 12 years, … fewer people who were treated with biologics—only one person out of the 92—developed psoriatic arthritis, and among the people who were on topicals only, it was 68. So 68 out of 600, that’s about 8%, and less than 1% for the biologic agent.”
“It would be great if that could be shown in a very large cohort,” Dr. Cush said.
Combating Hyperuricemia
The first abstract selected by Dr. Cush was from Poland, “Enteral Administration of ALLN-346, a Recombinant Urate-Degrading Enzyme, Decreases Serum Urate in a Pig Model of Hyperuricemia.”
“This is an animal model, of course, but the interesting thing here is that we know two-thirds of uric acid is excreted via the kidney, and one-third goes through the gut,” Dr. Cush said. “ALLN-346 is an early administered, non-absorbed, recombinant urate-degrading enzyme that’s taken orally and, therefore, helps reduce acid production in the GI [gastrointestinal] tract. They infused uric acid in the animals. They didn’t measure gout, just plasma uric acid levels. After they elevated those levels, they administered the recombinant protein, which showed a significant reduction in the uric acid levels from over 7 to 4.5.
“This might be a very manageable way of managing a very difficult disease,” Dr. Cush said.
MAS in sJIA
Dr. Cush next presented a late-breaking study from Italy, “Interferon-Gamma (IFN-γ) Neutralization with Emapalumab and Time to Response in Patients with Macrophage Activation Syndrome (MAS) Complicating Systemic Juvenile Idiopathic Arthritis (sJIA) Who Failed High-Dose Glucocorticoids.” In the study, researchers examined patients with patients with MAS on a background of sJIA and inadequate response to high-dose glucocorticoids.
“They were given a number of different injections of emapalumab, twice weekly up to four weeks,” Dr. Cush said. “All six patients receiving emapalumab achieved complete response. There was progressive improvement, their dependency on steroids dropped dramatically and subsequent normalization of all clinical and laboratory parameters occurred.”
Burnout
For Dr. Kavanaugh’s next choice, he admits he was a little biased because he co-authored the study, “Prevalence of Burnout in Rheumatology Professionals.”
The study measured the pervasiveness of burnout in a 129 rheumatology professionals using the Maslach Burnout Inventory (MBI); a 22-item questionnaire that includes three domains, emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (PA). Just over half the respondents (51%) reported burnout in at least one MBI classification; 37.5% of all respondents reported EE burnout, 30.5% DP burnout and 21% PA burnout. Twenty percent had burnout in one domain only, while 22.7% had burnout in two, and 7.8% had burnout in all three.
“It’s an important topic,” he said. “It affects all of us. It’s a problem we usually only whisper about and [don’t] admit to.”
Pregnancy
Both doctors liked two studies dealing with pregnancy, “Disease Flares Of Rheumatoid Arthritis [RA] During Pregnancy: 1) “What Is the Impact of Stopping bDMARDs at the Beginning of Pregnancy?” and 2) “Pregnancy in Rheumatoid Arthritis—Continue, Reduce or Stop TNF Inhibitors—a Prospective Observational Study.”
In the first study, based on acohort of 73 pregnancies in 63 RA patients, 37% experienced at least one flare during pregnancy despite the majority of the patients being in remission prior to conception. Researchers reported a threefold-increased chance of flare in patients who were on bDMARDs (and stopped the treatment early in pregnancy) compared with those who did not receive them. The researchers concluded that women may benefit from continuing treatment beyond conception.
Because women with active RA are more prone to relapses and complications during pregnancy, in the second study, based in Germany, of 70 completed pregnancies, subjects were grouped according to their decision to stop or continue TNF inhibitor (TNFi) therapy during their pregnancies. Researchers concluded that women with RA who discontinue TNFi at conception face a higher risk of flares during pregnancy and often have an increased demand for steroids to control disease activity.
“Pregnancy never used to be discussed at these meetings,” Dr. Cush said. “We’ve come around to the idea that a healthy baby is the result of a healthy mom. The ACR has done a good job with this, including its reproductive health initiative.”
Spondyloarthritis
Dr. Cush also discussed the abstract titled, “Diagnostic Delay in Spondyloarthritis.”
“In this study, they investigated 201 patients with low back pain. In 2010, it took an average of 48 months for low back pain patients to get to the rheumatologist, and in 2019, it’s 12 months. That’s a good trend, but there’s still work to be done,” he said.
Machine Learning
Finally, Dr. Kavanaugh noted the study, “Individually Tailored Predictions of Flare Probability for Rheumatoid Arthritis Patients on Biologic DMARDs Based on Machine Learning Stacking Meta-Classifier.”
In this study from Germany, researchers examined the clinical data of 41 RA patients on biologic DMARDs from a phase 3, multicenter, randomized, open, prospective, controlled, parallel-group study. Their results confirm the feasibility of guided tapering of conventional and biologic DMARDs based on machine-learning models and also proves that such models could be a reliable risk assessment tool for flare in the future.
“If there’s a theme at this [Annual Meeting], it seems to be a focus on the trend toward artificial intelligence and machine learning,” Dr. Kavanaugh said. “Almost every third poster is covering it. And I understand why. There’s too much data to wade through to make it meaningful. Machines can recognize patterns.”
Mike Fillon is a healthcare writer living in the Atlanta area.
Abstract Links
You can find all of the abstracts presented at the 2019 ACR/ARP Annual Meeting online.
