Dr. Blair Solow
ACR CONVERGENCE 2020—Held Nov. 5–9, the ACR’s first fully virtual annual meeting provided participants with a vast repository of new research related to rheumatoid arthritis (RA). To help you sort through the noise, Elizabeth (Blair) Solow, MD, an assistant professor of medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center, Dallas, offered her expertise. Her research interest is in rheumatoid arthritis and cardiovascular disease, and she participates in investigator-initiated clinical trials.
Abstract 0481—Subclinical Synovitis in Arthralgia: How Often Does It Result in Clinical Arthritis? A Longitudinal Study to Reflect on Starting Points for DMARD Treatment
Dr. Solow: The holy grail of managing autoimmunity would be preventing the disease in the first place. We know that autoantibodies may precede clinically apparent findings, and individuals who have a higher body mass index (abstract #1720), smoke or have poor dentition may be at higher risk for developing disease and a healthier lifestyle may reduce the risk of RA (abstract #1471). This study asks, if we can detect synovitis by either MRI or ultrasound, does this predict who may go on to develop overt clinically apparent RA? The short answer is, it depends. Individuals who were positive for anti-cyclic citrullinated peptide (CCP) antibodies were more likely than anti-CCP-negative patients to progress, but not all did. There are ongoing and completed clinical trials addressing the question if treating individuals with positive anti-CCP antibodies with disease-modifying anti-rheumatic drugs (DMARDs) may elongate onset or prevent the development of disease not only in RA. This study shows us we still need more biomarkers to determine who will go on to develop clinical arthritis.
Abstract 0939—Maintenance of Remission After Withdrawal of Etanercept or Methotrexate in Patients with Rheumatoid Arthritis in Sustained Remission on Combination Therapy: Results from a Randomized, Double-blind, Controlled Trial
Dr. Solow: Almost as soon as we start therapy for RA, patients will ask how long will they be on these medications and when they can start to taper. The ability to predict who will succeed with tapering immunosuppression and who needs long-term medications remains challenging. There have been studies examining strategies for tapering medications from decreasing doses until off vs. elongating the interval between doses. This study looks at which drug in combination therapy would be successful when tapering and finds etanercept monotherapy (or combination therapy) to be better at maintaining remission than methotrexate monotherapy. We need long-term data to determine the effects of how methotrexate may have affected anti-drug antibody formation and true long-term remission. This offers hope that some patients may be able to stay in remission with less medication.
Abstract 1998—Ten-year Analysis of the Risk of Severe Outcomes Related to Very Low-dose Glucocorticoids in Early Rheumatoid Arthritis
Dr. Solow: Glucocorticoids are often used to bring a patient relief more quickly while waiting for traditional DMARDs to kick in, to treat a flare or to bridge therapy adjustments. This study suggests that even at low doses, severe outcomes (including death, cardiovascular disease and infection) after long-term use are possible. We should be vigilant in reducing steroids to the lowest possible dose, and based on this study, tapering patients off.
Abstract 0233—Abatacept in Spanish Patients with Arthritis Rheumatoid and Interstitial Lung Disease. Multicenter Study of 263 Patients
Dr. Solow: In RA, interstitial lung disease (ILD) is a feared complication. ILD can be seen in up to 10% of RA patients, and it’s progressive. We have observational studies suggesting rituximab may be helpful in ILD; however, there are limited data on other therapy options. This study showed abatacept, after 12 months of follow-up, resulted in forced vital capacity (FVC), diffusion lung capacity for carbon monoxide (DLCO) and imaging that did not worsen. Limitations for this study include the observational nature, it was not blinded, and there was no control group. Further studies are needed; however, this is encouraging, especially in those patients with active joint disease.
Abstract L04—Influenza Adverse Events in Patients with Rheumatoid Arthritis in the Tofacitinib Clinical Program
Dr. Solow: Influenza is a common respiratory illness, and our patients are at higher risk for complications of the disease. This study evaluated trial data that allowed for the assessment of actual infections in patients taking tofacitinib. The results were comparable to methotrexate, adalimumab and, even, placebo. For the majority of the time, symptoms were mild, and doses were not held. In light of the COVID-19 pandemic, this is encouraging news.
Abstract 1994—Rheumatoid Arthritis Improvement After Exposure to an Anti-Inflammatory ‘ITIS’ Diet Is Associated with Changes of Gut Microbiome and Systemic Metabolome
Dr. Solow: So often I am asked, ‘Is there anything I can take or change in my diet that will help my RA?’ Here, we have a study suggesting that changes in the food we consume may affect not only our microbiome in the gut and the metabolites produced, but also clinical disease activity. Significant research is being done in this area as a possible source for the onset of autoimmunity, and it is encouraging to see that even after a patient is diagnosed with RA, specific food consumption may make a difference in clinical symptoms. How changing the microbiome and metabolome may affect long-term disease activity is under investigation.
Abstract 0493—Automatic Joint Space Assessment in Hand Radiographs with Deep Learning Among Patients with Rheumatoid Arthritis
Dr. Solow: Rheumatology patients are experiencing shortages in providers, and this will be exacerbated in the coming years. Other specialties, too, are feeling the shortage of available providers. Outsourcing specific tasks to computers that improve patient care and can be standardized is the (near) future. This study shows computer algorithms can detect and classify radiographic changes on par with rheumatologists. Computers should not replace providers. However, additional data that can be generated by computers to expand the patient story enhances our ability to care for patients.
Abstract 1445—Citrulline Reactive B Cells Are Present in the Lungs of Risk RA and Early Untreated RA
Dr. Solow: Where does RA start? This study isolated citrulline-reactive B cells producing pathogenic anti-citrullinated protein antibodies in the lungs of seropositive early stage RA patients. This finding supports the lung as a key site in the early phase of RA.
Abstract 0431—Hydroxychloroquine Use Was Not Associated with QTc Length in a Large Cohort of SLE and RA Patients
Dr. Solow: Given the cardiac events that occurred during the COVID-19 pandemic in the setting of using hydroxychloroquine (HCQ), providers are looking for any data that can guide the best steps in the care of patients with rheumatic disease . This study assessed prolonged QTc in RA and systemic lupus erythematosus. Those on HCQ did not have a prolonged QTc compared to those not on medications. Risk factors that were associated with prolongation included age, prednisone use and smoking, but, notably, not HCQ. However, this was a small, cross-sectional study and could not assess cumulative HCQ dosing, and excluded those with known cardiovascular disease.
Visit the ACR’s Meeting Abstracts site for more research presented at ACR Convergence 2020.
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