March 3, 2017

Feeling swell

The story

Let's be honest: you know way more about presidential tweets than you do about rheumatology. We've got you covered with the latest and greatest in rheumatoid arthritis. 

The background

Complications of rheumatoid arthritis (RA) stretch far beyond swollen joints. Patients suffer from structural damage to cartilage and bone, and face high rates of heart disease. Treatment starts with synthetic DMARDs, including RA elder statesman methotrexate, but things become murky for those who fail. Little evidence separates a set of new biologic agents that target cytokine-driven inflammation to control disease activity. Many are expensive infusions.

The beam

Instead of eliminating the inflammatory cytokines circulating in RA, JAK inhibitors disrupt their ability to signal changes inside the cell. RA-BEAM measured the efficacy of the oral JAK-inhibitor baractinib relative to placebo and standard-of-care TNF-alpha inhibitor adalimumab (Humira) in 1300 patients with active RA who failed treatment with methotrexate. After one year, baracitinib patients had fewer swollen joints and a greater decrease in inflammatory lab markers than patients treated with adalimumab infusion or placebo. 

The takeaway

One of the knocks on fancy RA infusions is that they are never compared to one another, so the makers of baracitinib get credit for pitting the drug head-to-head with Humira. Many hope that baracitinib pills will be less expensive than biologic infusions and more convenient for patients. Expect FDA approval soon.

Say it on rounds

When you can't quite describe a rash, but you can show a picture

A little imaging can spare a lot of trouble. Transrectal biopsy is used to confirm prostate cancer in men with elevated prostate specific antigen (PSA), but the procedure is invasive and can over-detect harmless cancers. A cohort study of 740 men found that multi-parametric prostate MRI prior to biopsy doubled the correct detection rate of aggressive cancers relative to biopsy alone (93% vs. 48%, respectively). MRI screening could allow up to one quarter of men with elevated PSAs to avoid biopsy, and could reduce the diagnosis of clinically insignificant cancers by 5%.

When you mix up your patient's meds 

You may be on to something. Small doses of anti-hypertensives can have big effects on blood pressure, while most side effects are dose dependent. A small proof-of-concept study found that a quarter-dose "quadpill" of common meds (irbesartan, amlodipine, HCTZ, and atenolol) lowered systolic blood pressure by an average of 20 mmHg relative to placebo with few side effects. The findings suggest that ultra-low-dose combination pills could be a well-tolerated and powerful clinical tool.

When your shift ends, and you can't remember where you left your pager 

Residency is known to cause foggy brain, but the condition is more alarming when it appears after chemotherapy. Patients with breast cancer who were treated with chemotherapy self-reported substantially more cognitive difficulties up to 6 months after treatment when compared to age-matched noncancer controls. Those with high baseline anxiety and depression levels were more likely to report perceived cognitive impairment following chemo, while the type and intensity of treatment regimen did not factor in results.

Brush up

Got the fever

Your friends and your patients go places. Sometimes they get fevers when they come back. Be on the lookout for life-threatening infections like malaria and enteric fever in patients returning from endemic areas. If there is suspicion for malaria, send a rapid diagnostic test and thick and thin smears. Isolate patients with risk factors for viral hemorrhagic fevers, and keep resistance patterns in mind when using antibiotics for severe infections.

What's the evidence

Behind, like, avoiding malaria in the first place? Following the emergence of widespread resistance to chloroquine, a benchmark 1993 study found weekly mefloquine to be an effective prophylaxis agent against P. falciparum in a study of 420 Peace Corps volunteers in West Africa. About a quarter of mefloquine users reported strange dreams. Atovaquone and proguanil (Malarone) also emerged as a safe and efficacious agent following a 1998 RCT of children in sub-Saharan Africa. 

What your lawyer friends are talking about

Conflict of interest. A new report found that over 80% of the largest patient advocacy groups received money from medical device and pharmaceutical companies. Over 40% had an industry executive on their governing board.

Spread the word

Send your interns something to look forward to.


We're on break the next two weeks as we set up shop for a monthlong stint in Edendale, South Africa. We'll be back with more on March 17th.

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