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Early, Aggressive and Seropositive (7.22.2022)

Jack Cush, MD

Dr. Jack Cush covers the news and journal reports from the past week on This week we have Insights NAFLD, overdose deaths, septic arthritis, refractory stills, & when MTX doesn’t work.

  1. Overdose deaths increased to 107 000 deaths in US in 2021, with significant racial disparity. Higher overdose rates seen in American Indian, Alaska Natives and Blacks. WORSE during COVID – 2020, overdose rates were 7 times higher in Blacks than Whites
  2. 0NHANES Cross-sectional study of 5672 psoriasis US adults (20-59 yrs) shows more NAFLD in PSO patients (33% vs 27% nonPSO) with an increased risk (OR 1.67) – moreso in men (OR 2.16), age 20-39 yrs (OR 2.48) & those without diabetes (OR 1.70)
  3. Metanalysis of 9 studies (RCTs, observational) looked @ DMARD effect (most Rx w/ biologics: TNFi, TCZ, RTX, Tofa) on lean & appendicular mass; shows despite bDMARD efficacy – no change in muscle mass! How will UR pts get STRONG?
  4. French study from 362 septic arthritis pts over 2 yrs., mean age was 64yrs, w/ high Charlson comorbidity index 3.5. Most common was Knee (39%), Staphylococcus (51%), Abx used 47d, surgery in 48%; 28% serious complications & 9.2% died
  5. 11.5% of Crohns pts have TNFi use contraindications (either MS, CHF, neoplasia, infx risk, TNFi AE, comorbidities, SLE. Alternatively GI survey respondents use ustekinumab (76%), vedolizumab (249%), or tofacitinib (0.5%)
  6. Metanalysis (48 pubs, 145 refract pts) of JAK inhibitors in myositis (DM, JDM) shows significant improvement in skin lesions, muscle weakness, and ILD.
  7. Leflunomide versus azathioprine in lupus nephritis? Study of 215 bx proven LN given either LEF or AZA – Renal flares were equal (15.7% v 17.8%), as was time to flare (16 mo vs AZA 14 mo); 24-hr proteinuria, creatinine, C3 and C4 improved similarly.
  8. 213 #SLE pts were screened for Cryoglobulinemia (2013 -2017); CG is frequent in SLE (66%), but mostly asymptomatic. Mean levels 40mg/L (0-228). Cryo Vasculitis in 15% w/ purpura, ulcers, digit ischemia, arthritis, GN (5%) or CNS (19%)
  9. Study of 50 #AOSD pts refractory to steroids (n=11), DMARDs (34) & biologics (n 30): given canakinumab 150–300 mg q 4wk (47) or q8wk(3). W/ 27 mos F/U: 78% complete resp w/in 3 mos (20% partial). Steroid sparing in 1/2, Low WBC 6%, 4%SIE
  10. 0*162 #AOSD or #sJIA criteria+ pts underwent genetic testing – 31% (51/162) had a genetic variant for periodic fever Dx. 4 SJIA pts were confirmed to have FMF or TRAPS. Genetic testing may be smart, esp w/ atypical presentations
  11. 2015 NEJM study of 4g acetaminophen vs PBO in 700 critically ill ICU patients with fever ≥38°C, showed Tylenol vs PBO had no differences in mortality, ICU stay or LFTs. Tylenol had small but signif reduction in Temp (38.4±1.0°C vs. 38.6±0.8°C; P<0.001)
  12. Abatacept Most Effective Early and in Seropositive RA
  13. Continue the Methotrexate, Leave the Cannoli



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