One of the highlights of day 2 was The Great Debate on treating subclinical RA. Plus vasculopathy vs vasculitis and PsA and SpA updates.
Trainee rheumatologists Dr Sadia Islam and Dr Maxine Isbel share their insights from Day 2 of ACR22.
DR SADIA ISLAM
The Great Debate: To treat or not? The role of DMARDs in subclinical rheumatoid arthritis
A stimulating debate on a clinical question often posed to rheumatologists in routine practice. Dr Michael Holers and Dr Kevin Deane in favour of treating, and Dr Hani El-Gabalawy and Dr Janet Pope in opposition, took us through this spirited and lively debate, central to which was defining subclinical or “pre-RA”.
Dr Holers discussed both non-articular and articular stages of pre-RA, prior to the development of clinical RA. Non-articular RA includes local and systemic autoimmunity, or an “autoimmuno-pathy”, where the presence of autoantibodies represents immunological unwellness even in the absence of inflammatory arthritis.
Targeting this non-articular stage may be most effective and provide additional systemic benefit as well as preventing or ameliorating future inflammatory arthritis.
Dr Holers also explored the implications of clinical RA, patient and healthcare costs and limited efficacy of treatments available for RA.
Dr Deane continued in further detail to outline the “causal endotypes hypothesis”, which highlighted how EBV and independent mucosal mechanisms in the lungs and gastrointestinal tract may be associated with pre-RA evolution and subsequent clinical endotypes.
This identifies potential targets for prevention at the level of the microbiome, mucosa or systemic immune response. However, interventions are not clearly identified and may not involve established DMARDs, though emerging evidence in the ARIAA study shows promising results.
Dr El-Gabalawy and Dr Pope appealed to us in the opposition with a re-enactment of a doctor-patient interaction that cleverly highlighted patient concerns regarding treatment – “Why should I take this drug?” “What are the side effects?” “Will I even develop RA?”.
Dr El-Gabalawy explored the window of opportunity in pre-RA and argued that treating at a stage when arthralgia is present is too late for prevention as the immune system is fully primed and the synovium is targeted, stating that delaying the development of RA is the only outcome.
Furthermore, not all patients who are seropositive progress to develop RA, with a similar proportion of patients becoming seronegative in 5-year follow up. Differentiating those who do and do not progress to RA and modifiable triggers still requires further research.
Dr Pope continued to discuss implications of DMARD treatment, including risks of overtreatment for those who may have never developed RA. She argued that similar results are achieved by doing nothing compared to the NNT with a DMARD to prevent 1 RA over the next year.
Dr Pope also highlighted the burden of care that may be imposed on the healthcare system with more patients without inflammatory arthritis requiring regular follow up, imaging, costs of medication as well as insurance and psychological impacts.
An impactful debate but the jury is still out.
Purple peripheries: vasculopathy vs vasculitis
This session started with an all too familiar scenario: the patient that presents with purple fingers leading to the consult that every rheumatologist loves to hear – “We don’t know what’s going on”.
Dr Philip Seo began the session by outlining the range of aetiologies for digital ischaemia, with rheumatological causes accounting for less than one third of cases. He further subdivided this into non-inflammatory and inflammatory conditions, providing a framework for work-up of these patients. With no doubt, the majority of non-inflammatory cases we encounter are related to scleroderma.
Inflammatory conditions include primary systemic vasculidities and rarely secondary vasculidities. Whilst large and small vessel vasculidities are not common causes of digital ischaemia, medium vessel vasculitis is worth considering, namely polyarteritis nodosa and rheumatoid vasculitis.
Notably, Dr Seo highlighted that tissue diagnosis is often difficult in medium vessel vasculitis due to accessibility, therefore assessing for medium vessel involvement in other territories, such as mononeuritis multiplex, is crucial for diagnosis. He concluded with the reminder that endocarditis can be a mimic of medium vessel vasculitis, both clinically and on angiography.
Dr Jeffrey Olin, a specialist in vascular medicine, gave us further insight into atheromatous embolisation as a cause of digital ischaemia and its close resemblance to necrotising vasculitis. A key message was the importance of managing cardiovascular risk factors with a high one-year mortality of 64-81% related to cardiovascular events. He also highlighted Buerger disease, with a surprising 30% of cases affecting females. Smoking cessation is fundamental, reducing risk of amputation to 5.5% versus 41%.
Needless to say, if we want to answer the questions “what’s going on?”, it is important to keep an open mind.
Dr Sadia Islam is a final year rheumatology advanced trainee at Royal Prince Alfred Hospital in Sydney.
DR MAXINE ISBEL
Spondyloarthritis and psoriatic arthritis: Updates from the research organisations
Throughout our medical career we are taught to be discerning consumers of knowledge. To select and apply research papers, medical scoring systems and algorithms from multiple domains to the infinitely complex human interactions that take place in our clinics. And observe outcomes. Over years this evolves into a gestalt, and then the challenge becomes staying current, while avoiding the echo chamber of our own carefully curated biases.
Guiding this journey at every level are professional bodies like ASAS and SPARTAN whose sole purpose is to analyse community needs, and focus resources on finding solutions. For the end user of their products, it is easy to remain blissfully ignorant of the activity occurring behind the scenes.
Which is why you should visit this community hub and listen to the updates from both ASAS and SPARTAN current presidents as they briefly lift the hood on the complex machinery of clinical research, education and advocacy. The structure, organisation and philosophy of these organisations will dictate their output, and that output is a spearhead in the wake of which we all practice.
For example, EULAR has run the difficult gauntlet of establishing classification criteria and validating novel imaging modalities. By necessity they have focussed on the refinement of a clinical definition of ankylosing spondylitis. As a result, perhaps engagement at the coal face was deprioritised for a time, and they have moved away from translational research.
These choices have consequences, one of which is that ASAS output in terms of education, assessment tools and apps is formidable to say the least. For that alone, it is worth watching to get an idea of what they have available.
SPARTAN, liberated from the need to define AS, is actively courting the experiences of practitioners and allied health engaging in care of AS patients outside of the tertiary centre of excellence.
I confess, not being based in the US and therefore unable to participate directly in SPARTAN, their community outreach efforts were of less interest to me. But their research agenda has flagged a few upcoming publications that will no doubt change practice yet again. And it complements the efforts of their European colleagues.
Both presidents are engaging speakers and address among other things the question of how to get involved, either as a consumer or via pathways to membership. By design these are somewhat exclusive organisations, which raises that issue of the echo chamber again.
Google tells me that there are 7.87 billion people in the world right now. ASAS and SPARTAN appear at a glance to have a combined membership of 330. All full members are sponsored by existing members and have a proven academic record, and whilst understandable, this creates bias. Perhaps it is a necessary one.
I look forward to exploring their websites and learning more about how these organisations keep themselves and the rest of us informed, while also keeping their ear to the ground. Twenty minutes for each was just not enough.
You can browse the organisation websites here:
ASAS www.asas-group.org
SPARTAN www.spartangroup.org
- 517. CH Spondyloarthritis and Psoriatic arthritis: Updates from the Research Organisations
Dr Maxine Isbel is a Perth-based final year rheumatology trainee and is currently doing a master’s in clinical research.
