TBD Meeting (4660-22)

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

The roots of treat-to-target (T2T) in rheumatology extend back over 30 years to the development of the 28-joint Disease Activity Score. Although it has been shown to be effective in clinical trials and has been included in guidelines, it has yet to be widely adopted in practice. The question remains: What is the role of T2T in rheumatology?

That’s what Jack Cush, MD, and Martin Bergman, MD, sought to answer in a point-counterpoint session at the 2022 Rheumatology Winter Clinical Symposium.

RWCS 2022 screenshot

“I do think that this is a concept we need to keep in mind, and it is a concept whose time is long overdue,” Dr. Bergman said in his presentation arguing in favor of T2T. “As good as you think you are – your ability to see the patient and determine how they’re doing – you’re not.”

But metrics alone are not enough to make clinical decisions, said Dr. Bergman, clinical professor of medicine at Drexel University, Philadelphia, citing a recommendation from 2014 recommendations on T2T published in Annals of the Rheumatic Diseases. “You don’t just follow a number. You have to take into consideration structural changes, functional impairment, comorbidities – and that’s going to adjust how you approach your patient and what you do with them.”

However, implementation of T2T to make changes in clinical practice in RA has been inconsistent. Referencing an abstract from the 2021 American College of Rheumatology annual meeting on 15-year follow-up for changing therapy in RA, Dr. Bergman argued it is not the patient who is unwilling to switch treatments. Between 2006 and 2021, patient unwillingness to change therapies decreased from 64% to 51%.

“What’s driving it mostly here [is] the doctor’s recommendation,” Dr. Bergman said. “And we know this is true because we’ve seen it in other studies.”

Many rheumatologists are “asleep at the wheel” when it comes to administering T2T, he said. “What we need to do is, after we wake up from this nap, we need to get back on the highway and drive to where we should be, which is treat-to-target.”

Dr. Bergman also shared his paradigm for administering T2T, which he noted does not typically take more than a few minutes to administer regardless of the measure chosen. “Pick a measure. I don’t care which measure you take. I personally use two: I like the RAPID3 and the CDAI,” he said. “But then, after you have the measure, evaluate the entire patient. Don’t just look at the number. Look at the patient, what’s going on, solid history, solid physical. And most importantly: Be a doctor, don’t be a computer screen.”

Problems in measurement of RA remission and adoption of T2T

Dr. Cush, who admitted early in his presentation that he is in favor of T2T, delivered his counterpoint somewhat tongue-in-cheek. However, he pointed out that there are several concerns about the goals in measuring outcomes in RA with T2T.

The goal in RA is disease remission, but how you define remission can vary, especially since sometimes there is evidence of synovitis or other disease activity visible through an exam or imaging, said Dr. Cush, a rheumatologist based in Dallas, and executive editor of RheumNow.com. Most of the evidence for T2T is in clinical trials, but adoption is inconsistent in clinical practice, and patients in general appear to be improving without widespread adoption, he argued.

“Are clinical trials the same as clinical practice?” he asked. “I think that this boils down to: Is this a quest for remissions, or the best-you-can-get, low disease activity state? Or is this a quest for physician change, which is actually the path you have to go through to get to remissions?”

“In the end, evidence that the metrics should drive prescribing, especially in private practice is, I think, lacking,” he said.

RWCS 2022 screenshot

Roy Fleischmann, MD, agreed with Dr. Cush’s point of how one defines disease remission, as well as Dr. Bergman’s paradigm for T2T. “If you’re a good rheumatologist, you really do examine joints,” but you also “take a look at patient function, patient global [assessment], your global [assessment], joint count,” he said. “You can put a number to it, but you have to take a look at all of that. Really, treat-to-target – it is all of that. It isn’t just looking at a number, it’s looking at everything. And the better that the patient can do, assuming comorbidities and everything else, the better it is.”

“The problem isn’t the patient. The problem isn’t the metric. The problem is the rheumatologist, because the rheumatologist isn’t putting in enough effort in order to reach that goal,” added Dr. Fleischmann, clinical professor of medicine at the University of Texas, Dallas, and codirector of the Metroplex Clinical Research Center, also in in Dallas.

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that T2T is “great for somebody who’s been doing it for a while, and seeing a lot of patients and has that comfort zone,” but he questioned whether new rheumatologists without a lot of clinical experience could apply the approach. “What information do they use to integrate, and how do they get to that point?” he asked. “I don’t have the answer to that.”

During a rebuttal, Dr. Bergman pushed back on the idea that clinical experience alone was enough. “You need something. You need a benchmark. You need something more than, ‘I say so.’ ”

“The problem is, we still haven’t convinced people to adopt them,” Dr. Bergman said. “And I think it’s failure of training because, in my opinion, I don’t know how you can do a modern current fellowship program and not teach metrics.”

Dr. Cush and Dr. Bergman used the same trials to argue for their side. “I think that us using the same slides, but maybe having different points, speaks to the problem,” Dr. Cush said. “And I choose not to make it the problem of the rheumatologists.”

“You’re in the field of pattern recognition,” Dr. Cush argued. “It’s a visual art. You can have all the numbers you want. You make the most of your decisions based on pattern recognition, which is not rooted in metrics, and that’s why you’re successful at what you do.

“I am a big believer in T2T, but I think you have to measure something, and you have to use it,” Dr. Cush closed. “And the problem is, we can’t be forced into this.”

Dr. Bergman and Dr. Cush reported having financial relationships with numerous pharmaceutical companies.

The roots of treat-to-target (T2T) in rheumatology extend back over 30 years to the development of the 28-joint Disease Activity Score. Although it has been shown to be effective in clinical trials and has been included in guidelines, it has yet to be widely adopted in practice. The question remains: What is the role of T2T in rheumatology?

That’s what Jack Cush, MD, and Martin Bergman, MD, sought to answer in a point-counterpoint session at the 2022 Rheumatology Winter Clinical Symposium.

RWCS 2022 screenshot

“I do think that this is a concept we need to keep in mind, and it is a concept whose time is long overdue,” Dr. Bergman said in his presentation arguing in favor of T2T. “As good as you think you are – your ability to see the patient and determine how they’re doing – you’re not.”

But metrics alone are not enough to make clinical decisions, said Dr. Bergman, clinical professor of medicine at Drexel University, Philadelphia, citing a recommendation from 2014 recommendations on T2T published in Annals of the Rheumatic Diseases. “You don’t just follow a number. You have to take into consideration structural changes, functional impairment, comorbidities – and that’s going to adjust how you approach your patient and what you do with them.”

However, implementation of T2T to make changes in clinical practice in RA has been inconsistent. Referencing an abstract from the 2021 American College of Rheumatology annual meeting on 15-year follow-up for changing therapy in RA, Dr. Bergman argued it is not the patient who is unwilling to switch treatments. Between 2006 and 2021, patient unwillingness to change therapies decreased from 64% to 51%.

“What’s driving it mostly here [is] the doctor’s recommendation,” Dr. Bergman said. “And we know this is true because we’ve seen it in other studies.”

Many rheumatologists are “asleep at the wheel” when it comes to administering T2T, he said. “What we need to do is, after we wake up from this nap, we need to get back on the highway and drive to where we should be, which is treat-to-target.”

Dr. Bergman also shared his paradigm for administering T2T, which he noted does not typically take more than a few minutes to administer regardless of the measure chosen. “Pick a measure. I don’t care which measure you take. I personally use two: I like the RAPID3 and the CDAI,” he said. “But then, after you have the measure, evaluate the entire patient. Don’t just look at the number. Look at the patient, what’s going on, solid history, solid physical. And most importantly: Be a doctor, don’t be a computer screen.”

Problems in measurement of RA remission and adoption of T2T

Dr. Cush, who admitted early in his presentation that he is in favor of T2T, delivered his counterpoint somewhat tongue-in-cheek. However, he pointed out that there are several concerns about the goals in measuring outcomes in RA with T2T.

The goal in RA is disease remission, but how you define remission can vary, especially since sometimes there is evidence of synovitis or other disease activity visible through an exam or imaging, said Dr. Cush, a rheumatologist based in Dallas, and executive editor of RheumNow.com. Most of the evidence for T2T is in clinical trials, but adoption is inconsistent in clinical practice, and patients in general appear to be improving without widespread adoption, he argued.

“Are clinical trials the same as clinical practice?” he asked. “I think that this boils down to: Is this a quest for remissions, or the best-you-can-get, low disease activity state? Or is this a quest for physician change, which is actually the path you have to go through to get to remissions?”

“In the end, evidence that the metrics should drive prescribing, especially in private practice is, I think, lacking,” he said.

RWCS 2022 screenshot

Roy Fleischmann, MD, agreed with Dr. Cush’s point of how one defines disease remission, as well as Dr. Bergman’s paradigm for T2T. “If you’re a good rheumatologist, you really do examine joints,” but you also “take a look at patient function, patient global [assessment], your global [assessment], joint count,” he said. “You can put a number to it, but you have to take a look at all of that. Really, treat-to-target – it is all of that. It isn’t just looking at a number, it’s looking at everything. And the better that the patient can do, assuming comorbidities and everything else, the better it is.”

“The problem isn’t the patient. The problem isn’t the metric. The problem is the rheumatologist, because the rheumatologist isn’t putting in enough effort in order to reach that goal,” added Dr. Fleischmann, clinical professor of medicine at the University of Texas, Dallas, and codirector of the Metroplex Clinical Research Center, also in in Dallas.

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that T2T is “great for somebody who’s been doing it for a while, and seeing a lot of patients and has that comfort zone,” but he questioned whether new rheumatologists without a lot of clinical experience could apply the approach. “What information do they use to integrate, and how do they get to that point?” he asked. “I don’t have the answer to that.”

During a rebuttal, Dr. Bergman pushed back on the idea that clinical experience alone was enough. “You need something. You need a benchmark. You need something more than, ‘I say so.’ ”

“The problem is, we still haven’t convinced people to adopt them,” Dr. Bergman said. “And I think it’s failure of training because, in my opinion, I don’t know how you can do a modern current fellowship program and not teach metrics.”

Dr. Cush and Dr. Bergman used the same trials to argue for their side. “I think that us using the same slides, but maybe having different points, speaks to the problem,” Dr. Cush said. “And I choose not to make it the problem of the rheumatologists.”

“You’re in the field of pattern recognition,” Dr. Cush argued. “It’s a visual art. You can have all the numbers you want. You make the most of your decisions based on pattern recognition, which is not rooted in metrics, and that’s why you’re successful at what you do.

“I am a big believer in T2T, but I think you have to measure something, and you have to use it,” Dr. Cush closed. “And the problem is, we can’t be forced into this.”

Dr. Bergman and Dr. Cush reported having financial relationships with numerous pharmaceutical companies.

The roots of treat-to-target (T2T) in rheumatology extend back over 30 years to the development of the 28-joint Disease Activity Score. Although it has been shown to be effective in clinical trials and has been included in guidelines, it has yet to be widely adopted in practice. The question remains: What is the role of T2T in rheumatology?

That’s what Jack Cush, MD, and Martin Bergman, MD, sought to answer in a point-counterpoint session at the 2022 Rheumatology Winter Clinical Symposium.

RWCS 2022 screenshot

“I do think that this is a concept we need to keep in mind, and it is a concept whose time is long overdue,” Dr. Bergman said in his presentation arguing in favor of T2T. “As good as you think you are – your ability to see the patient and determine how they’re doing – you’re not.”

But metrics alone are not enough to make clinical decisions, said Dr. Bergman, clinical professor of medicine at Drexel University, Philadelphia, citing a recommendation from 2014 recommendations on T2T published in Annals of the Rheumatic Diseases. “You don’t just follow a number. You have to take into consideration structural changes, functional impairment, comorbidities – and that’s going to adjust how you approach your patient and what you do with them.”

However, implementation of T2T to make changes in clinical practice in RA has been inconsistent. Referencing an abstract from the 2021 American College of Rheumatology annual meeting on 15-year follow-up for changing therapy in RA, Dr. Bergman argued it is not the patient who is unwilling to switch treatments. Between 2006 and 2021, patient unwillingness to change therapies decreased from 64% to 51%.

“What’s driving it mostly here [is] the doctor’s recommendation,” Dr. Bergman said. “And we know this is true because we’ve seen it in other studies.”

Many rheumatologists are “asleep at the wheel” when it comes to administering T2T, he said. “What we need to do is, after we wake up from this nap, we need to get back on the highway and drive to where we should be, which is treat-to-target.”

Dr. Bergman also shared his paradigm for administering T2T, which he noted does not typically take more than a few minutes to administer regardless of the measure chosen. “Pick a measure. I don’t care which measure you take. I personally use two: I like the RAPID3 and the CDAI,” he said. “But then, after you have the measure, evaluate the entire patient. Don’t just look at the number. Look at the patient, what’s going on, solid history, solid physical. And most importantly: Be a doctor, don’t be a computer screen.”

Problems in measurement of RA remission and adoption of T2T

Dr. Cush, who admitted early in his presentation that he is in favor of T2T, delivered his counterpoint somewhat tongue-in-cheek. However, he pointed out that there are several concerns about the goals in measuring outcomes in RA with T2T.

The goal in RA is disease remission, but how you define remission can vary, especially since sometimes there is evidence of synovitis or other disease activity visible through an exam or imaging, said Dr. Cush, a rheumatologist based in Dallas, and executive editor of RheumNow.com. Most of the evidence for T2T is in clinical trials, but adoption is inconsistent in clinical practice, and patients in general appear to be improving without widespread adoption, he argued.

“Are clinical trials the same as clinical practice?” he asked. “I think that this boils down to: Is this a quest for remissions, or the best-you-can-get, low disease activity state? Or is this a quest for physician change, which is actually the path you have to go through to get to remissions?”

“In the end, evidence that the metrics should drive prescribing, especially in private practice is, I think, lacking,” he said.

RWCS 2022 screenshot

Roy Fleischmann, MD, agreed with Dr. Cush’s point of how one defines disease remission, as well as Dr. Bergman’s paradigm for T2T. “If you’re a good rheumatologist, you really do examine joints,” but you also “take a look at patient function, patient global [assessment], your global [assessment], joint count,” he said. “You can put a number to it, but you have to take a look at all of that. Really, treat-to-target – it is all of that. It isn’t just looking at a number, it’s looking at everything. And the better that the patient can do, assuming comorbidities and everything else, the better it is.”

“The problem isn’t the patient. The problem isn’t the metric. The problem is the rheumatologist, because the rheumatologist isn’t putting in enough effort in order to reach that goal,” added Dr. Fleischmann, clinical professor of medicine at the University of Texas, Dallas, and codirector of the Metroplex Clinical Research Center, also in in Dallas.

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that T2T is “great for somebody who’s been doing it for a while, and seeing a lot of patients and has that comfort zone,” but he questioned whether new rheumatologists without a lot of clinical experience could apply the approach. “What information do they use to integrate, and how do they get to that point?” he asked. “I don’t have the answer to that.”

During a rebuttal, Dr. Bergman pushed back on the idea that clinical experience alone was enough. “You need something. You need a benchmark. You need something more than, ‘I say so.’ ”

“The problem is, we still haven’t convinced people to adopt them,” Dr. Bergman said. “And I think it’s failure of training because, in my opinion, I don’t know how you can do a modern current fellowship program and not teach metrics.”

Dr. Cush and Dr. Bergman used the same trials to argue for their side. “I think that us using the same slides, but maybe having different points, speaks to the problem,” Dr. Cush said. “And I choose not to make it the problem of the rheumatologists.”

“You’re in the field of pattern recognition,” Dr. Cush argued. “It’s a visual art. You can have all the numbers you want. You make the most of your decisions based on pattern recognition, which is not rooted in metrics, and that’s why you’re successful at what you do.

“I am a big believer in T2T, but I think you have to measure something, and you have to use it,” Dr. Cush closed. “And the problem is, we can’t be forced into this.”

Dr. Bergman and Dr. Cush reported having financial relationships with numerous pharmaceutical companies.

The COVID-19 pandemic led to a decrease in the proportion of patients with rheumatic diseases who stopped taking their disease-modifying antirheumatic drugs (DMARDs), but the percentage who interrupted DMARD treatment increased later in the pandemic, according to speakers at the 2022 Rheumatology Winter Clinical Symposium.

“People seem to be less anxious, but they’re interrupting their DMARD therapy more, more recently than in the pits of COVID, if you will,” said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS.

RWCS 2022 screenshot

Dr. Kavanaugh and his copresenter Jack Cush, MD, were discussing the results of a recent study published in Arthritis Care & Research that evaluated 2,424 patients with rheumatic diseases who completed a baseline and at least one follow-up survey issued by patient organizations between March 2020 and May 2021, with a median of five follow-up surveys completed. The patients included in the study were aged a mean of 57 years, 86.6% were women, 90.5% were White, 41.8% had rheumatoid arthritis (RA), 14.8% had antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and 12.4% had psoriatic arthritis. Overall, 52.6% were on biologics or a Janus kinase (JAK) inhibitor, 30.0% were receiving methotrexate, 21.4% were taking hydroxychloroquine, and 28.6% were receiving low-dose (24.0%) or high-dose (4.6%) glucocorticoids.

Patients’ T-scores on the anxiety short form Patient-Reported Outcomes Measurement Information System (PROMIS) survey significantly decreased from a score of 58.7 in April 2020 to a score of 53.7 in May 2021 (P < .001), but there was a significant decrease in the interruption of DMARD treatment between April and December 2020 (11.2% vs. 7.5%; P < .001). This percentage rose significantly to 14.0% by May 2021 (P < .001). Patients who stopped using DMARDs were significantly associated with predicted incidence of severe flare in the next survey in adjusted models (12.9% vs. 8.0%; odds ratio, 1.71; 95% confidence interval, 1.23-2.36).

The results tell us “that we as a discipline are not doing a good job educating our patients,” said Dr. Cush, a rheumatologist based in Dallas, Tex., and executive editor of RheumNow.com.

“I wish we – and I’m really talking about myself – but myself and my practice were more proactive when COVID happened [in] sending out regular bulletins: ‘Don’t stop your therapy; these are the things you get; get the test that you need to get done,’ ” he said. “We let a lot of things go on autopilot with the patient driving throughout COVID. Even now, it’s happening. And this is a problem, and there are going to be consequences to this.”

Dr. Kavanaugh agreed with Dr. Cush’s assessment, suggesting that the pandemic came up quickly enough that it was difficult to be proactive with the situation.
 

Patients on JAK inhibitors as new COVID-19 risk group?

Another standout study on COVID-19 from 2021 was an analysis of the COVID-19 Global Rheumatology Alliance physician registry that examined risk of COVID-19 severity for patients with RA taking biologic or targeted synthetic DMARDs (tsDMARDs), which was presented at the 2021 EULAR congress and later published in Annals of the Rheumatic Diseases.

The researchers evaluated 2,869 patients March 2020 and April 2021 who were receiving abatacept (237 patients), rituximab (364 patients), interleukin (IL)-6 inhibitors (317 patients), JAK inhibitors (563 patients), or tumor necrosis factor (TNF) inhibitors such as infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab (1,388 patients) before developing COVID-19. Data about biologics or tsDMARDs were collected as a drug class. Patients in the study were mostly White (69.0%) women (80.8%) with a mean age of 56.7 years who lived in Europe (51.8%) or North America (35.0%). The researchers examined the severity of COVID-19 among all patients studied and calculated odds ratios based on drug class, with the TNF inhibitor group serving as a reference.

“[I]n this case, they said that the baseline use of rituximab was associated with more severity, and you see the severity being hospitalization and ICU and deaths. They found a signal for the JAK inhibitors that is not found in the other studies,” Dr. Kavanaugh said.

Overall, they found 21% of patients in the registry were hospitalized and 5.5% died, with rituximab (OR, 4.15; 95% CI, 3.16-5.44) and JAK inhibitors (OR, 2.06; 95% CI, 1.60-2.65) associated with more severe COVID-19 outcomes. Specifically, rituximab was associated with greater likelihood of hospitalization (OR, 4.53; 95% CI, 3.32-6.18), hospitalization with oxygen/ventilation (OR, 2.87; 95% CI, 2.03-4.06), need for mechanical ventilation (OR, 4.05; 95% CI, 3.08-5.33), and mortality (OR, 4.57; 95% CI, 3.32-9.01), compared with TNF inhibitors. For JAK inhibitors, there was also a greater likelihood of hospitalization (OR, 2.40; 95% CI, 1.78-3.24), hospitalization with oxygen/ventilation (OR, 1.55; 95% CI, 1.04-2.18), need for mechanical ventilation (OR, 2.03; 95% CI, 1.56-2.62), and mortality (OR, 2.04; 95% CI, 1.58-2.65), compared with the TNF inhibitors group. Associations between COVID-19 severity and abatacept or IL-6 inhibitors were not identified.

Commenting on the study in a question-and-answer session, Roy Fleischmann, MD, said the part of the study that identified a signal for JAK inhibitors was “very interesting.” He called attention to a rapid response comment to the study, which questioned if it was the drug class itself that caused the risk for severe disease. “This is very important, because actually, the patients who stop the JAK [inhibitor], that’s what drove the illness. The patients [who] continued the JAK [inhibitor], very few of them had illness,” said Dr. Fleischmann, clinical professor of medicine at the University of Texas Southwestern Medical School and codirector of the Metroplex Clinical Research Center, both in Dallas, Tex.
 

Confusion among patients during COVID-19

Alvin Wells, MD, PhD, asked the copresenters during the Q&A session whether they had any clinical pearls for the audience on how they manage treatment of patients with rheumatic disease with potential COVID-19 risk. “I think the confusion with our patients and COVID is what the ACR has put out with their guidelines,” said Dr. Wells, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc.

Dr. Cush said he has three rules he follows: lower and discontinue steroids, avoid rituximab as a starting treatment and negotiate if patients are already taking it, and don’t stop any therapy.

“I want disease control. I think being under control is what keeps you away from risk of COVID and hospitalization,” Dr. Cush said. “I think being uncontrolled and inflamed, whether it’s our [patients with] inflammatory arthritis or lupus or, worse, vasculitis [or] myositis, those are the ones at high risk of progression from being just infected to being sick and in the hospital.”

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, posed the question of getting somewhat back to normal during COVID-19 with regard to recently infected patients presenting at infusion centers, whether patients are more likely to continue testing positive, and when patients are cleared to come back. Dr. Ruderman said his center has a 20-day rule for returning after having COVID-19, while Dr. Cush said his center allows patients to come in if they test negative after 7-10 days.

“One of the things we’re struggling with is our infusion center, and one of the questions that keeps coming up is when can people come back after a COVID infection?” he said. “If you’re on a drug at home, that’s up to you and the patient. But in the infusion [center], then you have other people sitting around there.”

Dr. Kavanaugh said there is no current data for how long patients with rheumatic disease shed virus, or how long a positive test can be measured. “You definitely will continue to shed, and you’ll be detectable for a while,” he said.

Dr. Cush and Dr. Kavanaugh reported having financial relationships with numerous pharmaceutical companies.

The COVID-19 pandemic led to a decrease in the proportion of patients with rheumatic diseases who stopped taking their disease-modifying antirheumatic drugs (DMARDs), but the percentage who interrupted DMARD treatment increased later in the pandemic, according to speakers at the 2022 Rheumatology Winter Clinical Symposium.

“People seem to be less anxious, but they’re interrupting their DMARD therapy more, more recently than in the pits of COVID, if you will,” said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS.

RWCS 2022 screenshot

Dr. Kavanaugh and his copresenter Jack Cush, MD, were discussing the results of a recent study published in Arthritis Care & Research that evaluated 2,424 patients with rheumatic diseases who completed a baseline and at least one follow-up survey issued by patient organizations between March 2020 and May 2021, with a median of five follow-up surveys completed. The patients included in the study were aged a mean of 57 years, 86.6% were women, 90.5% were White, 41.8% had rheumatoid arthritis (RA), 14.8% had antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and 12.4% had psoriatic arthritis. Overall, 52.6% were on biologics or a Janus kinase (JAK) inhibitor, 30.0% were receiving methotrexate, 21.4% were taking hydroxychloroquine, and 28.6% were receiving low-dose (24.0%) or high-dose (4.6%) glucocorticoids.

Patients’ T-scores on the anxiety short form Patient-Reported Outcomes Measurement Information System (PROMIS) survey significantly decreased from a score of 58.7 in April 2020 to a score of 53.7 in May 2021 (P < .001), but there was a significant decrease in the interruption of DMARD treatment between April and December 2020 (11.2% vs. 7.5%; P < .001). This percentage rose significantly to 14.0% by May 2021 (P < .001). Patients who stopped using DMARDs were significantly associated with predicted incidence of severe flare in the next survey in adjusted models (12.9% vs. 8.0%; odds ratio, 1.71; 95% confidence interval, 1.23-2.36).

The results tell us “that we as a discipline are not doing a good job educating our patients,” said Dr. Cush, a rheumatologist based in Dallas, Tex., and executive editor of RheumNow.com.

“I wish we – and I’m really talking about myself – but myself and my practice were more proactive when COVID happened [in] sending out regular bulletins: ‘Don’t stop your therapy; these are the things you get; get the test that you need to get done,’ ” he said. “We let a lot of things go on autopilot with the patient driving throughout COVID. Even now, it’s happening. And this is a problem, and there are going to be consequences to this.”

Dr. Kavanaugh agreed with Dr. Cush’s assessment, suggesting that the pandemic came up quickly enough that it was difficult to be proactive with the situation.
 

Patients on JAK inhibitors as new COVID-19 risk group?

Another standout study on COVID-19 from 2021 was an analysis of the COVID-19 Global Rheumatology Alliance physician registry that examined risk of COVID-19 severity for patients with RA taking biologic or targeted synthetic DMARDs (tsDMARDs), which was presented at the 2021 EULAR congress and later published in Annals of the Rheumatic Diseases.

The researchers evaluated 2,869 patients March 2020 and April 2021 who were receiving abatacept (237 patients), rituximab (364 patients), interleukin (IL)-6 inhibitors (317 patients), JAK inhibitors (563 patients), or tumor necrosis factor (TNF) inhibitors such as infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab (1,388 patients) before developing COVID-19. Data about biologics or tsDMARDs were collected as a drug class. Patients in the study were mostly White (69.0%) women (80.8%) with a mean age of 56.7 years who lived in Europe (51.8%) or North America (35.0%). The researchers examined the severity of COVID-19 among all patients studied and calculated odds ratios based on drug class, with the TNF inhibitor group serving as a reference.

“[I]n this case, they said that the baseline use of rituximab was associated with more severity, and you see the severity being hospitalization and ICU and deaths. They found a signal for the JAK inhibitors that is not found in the other studies,” Dr. Kavanaugh said.

Overall, they found 21% of patients in the registry were hospitalized and 5.5% died, with rituximab (OR, 4.15; 95% CI, 3.16-5.44) and JAK inhibitors (OR, 2.06; 95% CI, 1.60-2.65) associated with more severe COVID-19 outcomes. Specifically, rituximab was associated with greater likelihood of hospitalization (OR, 4.53; 95% CI, 3.32-6.18), hospitalization with oxygen/ventilation (OR, 2.87; 95% CI, 2.03-4.06), need for mechanical ventilation (OR, 4.05; 95% CI, 3.08-5.33), and mortality (OR, 4.57; 95% CI, 3.32-9.01), compared with TNF inhibitors. For JAK inhibitors, there was also a greater likelihood of hospitalization (OR, 2.40; 95% CI, 1.78-3.24), hospitalization with oxygen/ventilation (OR, 1.55; 95% CI, 1.04-2.18), need for mechanical ventilation (OR, 2.03; 95% CI, 1.56-2.62), and mortality (OR, 2.04; 95% CI, 1.58-2.65), compared with the TNF inhibitors group. Associations between COVID-19 severity and abatacept or IL-6 inhibitors were not identified.

Commenting on the study in a question-and-answer session, Roy Fleischmann, MD, said the part of the study that identified a signal for JAK inhibitors was “very interesting.” He called attention to a rapid response comment to the study, which questioned if it was the drug class itself that caused the risk for severe disease. “This is very important, because actually, the patients who stop the JAK [inhibitor], that’s what drove the illness. The patients [who] continued the JAK [inhibitor], very few of them had illness,” said Dr. Fleischmann, clinical professor of medicine at the University of Texas Southwestern Medical School and codirector of the Metroplex Clinical Research Center, both in Dallas, Tex.
 

Confusion among patients during COVID-19

Alvin Wells, MD, PhD, asked the copresenters during the Q&A session whether they had any clinical pearls for the audience on how they manage treatment of patients with rheumatic disease with potential COVID-19 risk. “I think the confusion with our patients and COVID is what the ACR has put out with their guidelines,” said Dr. Wells, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc.

Dr. Cush said he has three rules he follows: lower and discontinue steroids, avoid rituximab as a starting treatment and negotiate if patients are already taking it, and don’t stop any therapy.

“I want disease control. I think being under control is what keeps you away from risk of COVID and hospitalization,” Dr. Cush said. “I think being uncontrolled and inflamed, whether it’s our [patients with] inflammatory arthritis or lupus or, worse, vasculitis [or] myositis, those are the ones at high risk of progression from being just infected to being sick and in the hospital.”

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, posed the question of getting somewhat back to normal during COVID-19 with regard to recently infected patients presenting at infusion centers, whether patients are more likely to continue testing positive, and when patients are cleared to come back. Dr. Ruderman said his center has a 20-day rule for returning after having COVID-19, while Dr. Cush said his center allows patients to come in if they test negative after 7-10 days.

“One of the things we’re struggling with is our infusion center, and one of the questions that keeps coming up is when can people come back after a COVID infection?” he said. “If you’re on a drug at home, that’s up to you and the patient. But in the infusion [center], then you have other people sitting around there.”

Dr. Kavanaugh said there is no current data for how long patients with rheumatic disease shed virus, or how long a positive test can be measured. “You definitely will continue to shed, and you’ll be detectable for a while,” he said.

Dr. Cush and Dr. Kavanaugh reported having financial relationships with numerous pharmaceutical companies.

The COVID-19 pandemic led to a decrease in the proportion of patients with rheumatic diseases who stopped taking their disease-modifying antirheumatic drugs (DMARDs), but the percentage who interrupted DMARD treatment increased later in the pandemic, according to speakers at the 2022 Rheumatology Winter Clinical Symposium.

“People seem to be less anxious, but they’re interrupting their DMARD therapy more, more recently than in the pits of COVID, if you will,” said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS.

RWCS 2022 screenshot

Dr. Kavanaugh and his copresenter Jack Cush, MD, were discussing the results of a recent study published in Arthritis Care & Research that evaluated 2,424 patients with rheumatic diseases who completed a baseline and at least one follow-up survey issued by patient organizations between March 2020 and May 2021, with a median of five follow-up surveys completed. The patients included in the study were aged a mean of 57 years, 86.6% were women, 90.5% were White, 41.8% had rheumatoid arthritis (RA), 14.8% had antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and 12.4% had psoriatic arthritis. Overall, 52.6% were on biologics or a Janus kinase (JAK) inhibitor, 30.0% were receiving methotrexate, 21.4% were taking hydroxychloroquine, and 28.6% were receiving low-dose (24.0%) or high-dose (4.6%) glucocorticoids.

Patients’ T-scores on the anxiety short form Patient-Reported Outcomes Measurement Information System (PROMIS) survey significantly decreased from a score of 58.7 in April 2020 to a score of 53.7 in May 2021 (P < .001), but there was a significant decrease in the interruption of DMARD treatment between April and December 2020 (11.2% vs. 7.5%; P < .001). This percentage rose significantly to 14.0% by May 2021 (P < .001). Patients who stopped using DMARDs were significantly associated with predicted incidence of severe flare in the next survey in adjusted models (12.9% vs. 8.0%; odds ratio, 1.71; 95% confidence interval, 1.23-2.36).

The results tell us “that we as a discipline are not doing a good job educating our patients,” said Dr. Cush, a rheumatologist based in Dallas, Tex., and executive editor of RheumNow.com.

“I wish we – and I’m really talking about myself – but myself and my practice were more proactive when COVID happened [in] sending out regular bulletins: ‘Don’t stop your therapy; these are the things you get; get the test that you need to get done,’ ” he said. “We let a lot of things go on autopilot with the patient driving throughout COVID. Even now, it’s happening. And this is a problem, and there are going to be consequences to this.”

Dr. Kavanaugh agreed with Dr. Cush’s assessment, suggesting that the pandemic came up quickly enough that it was difficult to be proactive with the situation.
 

Patients on JAK inhibitors as new COVID-19 risk group?

Another standout study on COVID-19 from 2021 was an analysis of the COVID-19 Global Rheumatology Alliance physician registry that examined risk of COVID-19 severity for patients with RA taking biologic or targeted synthetic DMARDs (tsDMARDs), which was presented at the 2021 EULAR congress and later published in Annals of the Rheumatic Diseases.

The researchers evaluated 2,869 patients March 2020 and April 2021 who were receiving abatacept (237 patients), rituximab (364 patients), interleukin (IL)-6 inhibitors (317 patients), JAK inhibitors (563 patients), or tumor necrosis factor (TNF) inhibitors such as infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab (1,388 patients) before developing COVID-19. Data about biologics or tsDMARDs were collected as a drug class. Patients in the study were mostly White (69.0%) women (80.8%) with a mean age of 56.7 years who lived in Europe (51.8%) or North America (35.0%). The researchers examined the severity of COVID-19 among all patients studied and calculated odds ratios based on drug class, with the TNF inhibitor group serving as a reference.

“[I]n this case, they said that the baseline use of rituximab was associated with more severity, and you see the severity being hospitalization and ICU and deaths. They found a signal for the JAK inhibitors that is not found in the other studies,” Dr. Kavanaugh said.

Overall, they found 21% of patients in the registry were hospitalized and 5.5% died, with rituximab (OR, 4.15; 95% CI, 3.16-5.44) and JAK inhibitors (OR, 2.06; 95% CI, 1.60-2.65) associated with more severe COVID-19 outcomes. Specifically, rituximab was associated with greater likelihood of hospitalization (OR, 4.53; 95% CI, 3.32-6.18), hospitalization with oxygen/ventilation (OR, 2.87; 95% CI, 2.03-4.06), need for mechanical ventilation (OR, 4.05; 95% CI, 3.08-5.33), and mortality (OR, 4.57; 95% CI, 3.32-9.01), compared with TNF inhibitors. For JAK inhibitors, there was also a greater likelihood of hospitalization (OR, 2.40; 95% CI, 1.78-3.24), hospitalization with oxygen/ventilation (OR, 1.55; 95% CI, 1.04-2.18), need for mechanical ventilation (OR, 2.03; 95% CI, 1.56-2.62), and mortality (OR, 2.04; 95% CI, 1.58-2.65), compared with the TNF inhibitors group. Associations between COVID-19 severity and abatacept or IL-6 inhibitors were not identified.

Commenting on the study in a question-and-answer session, Roy Fleischmann, MD, said the part of the study that identified a signal for JAK inhibitors was “very interesting.” He called attention to a rapid response comment to the study, which questioned if it was the drug class itself that caused the risk for severe disease. “This is very important, because actually, the patients who stop the JAK [inhibitor], that’s what drove the illness. The patients [who] continued the JAK [inhibitor], very few of them had illness,” said Dr. Fleischmann, clinical professor of medicine at the University of Texas Southwestern Medical School and codirector of the Metroplex Clinical Research Center, both in Dallas, Tex.
 

Confusion among patients during COVID-19

Alvin Wells, MD, PhD, asked the copresenters during the Q&A session whether they had any clinical pearls for the audience on how they manage treatment of patients with rheumatic disease with potential COVID-19 risk. “I think the confusion with our patients and COVID is what the ACR has put out with their guidelines,” said Dr. Wells, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc.

Dr. Cush said he has three rules he follows: lower and discontinue steroids, avoid rituximab as a starting treatment and negotiate if patients are already taking it, and don’t stop any therapy.

“I want disease control. I think being under control is what keeps you away from risk of COVID and hospitalization,” Dr. Cush said. “I think being uncontrolled and inflamed, whether it’s our [patients with] inflammatory arthritis or lupus or, worse, vasculitis [or] myositis, those are the ones at high risk of progression from being just infected to being sick and in the hospital.”

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, posed the question of getting somewhat back to normal during COVID-19 with regard to recently infected patients presenting at infusion centers, whether patients are more likely to continue testing positive, and when patients are cleared to come back. Dr. Ruderman said his center has a 20-day rule for returning after having COVID-19, while Dr. Cush said his center allows patients to come in if they test negative after 7-10 days.

“One of the things we’re struggling with is our infusion center, and one of the questions that keeps coming up is when can people come back after a COVID infection?” he said. “If you’re on a drug at home, that’s up to you and the patient. But in the infusion [center], then you have other people sitting around there.”

Dr. Kavanaugh said there is no current data for how long patients with rheumatic disease shed virus, or how long a positive test can be measured. “You definitely will continue to shed, and you’ll be detectable for a while,” he said.

Dr. Cush and Dr. Kavanaugh reported having financial relationships with numerous pharmaceutical companies.