Highlights from the Northwest Rheumatism Society annual conference held April 29 May 1, 2010 in Vancouver British Columbia Canada.
This was a decidedly Canadian agenda with nearly all speakers coming from that country
with the exception of Prof. Ian McInnes who flew over from Glasgow Scotland. There
were several well-known, outstanding experts including Dr. McInnis, Dr. Jonathan
Adachi who spoke on osteoporosis Dr. Simon Carette who spoke on vasculitis and Dr.
Hyon Choi who spoke on gout. The social highlight was a private viewing of Leonardo
da Vinci's anatomic drawings which was held at the Vancouver Art Gallery.
Dr. McInnis reviewed the interface between genetic predisposition with environmental
triggers for rheumatoid arthritis (RA). He pointed to Lars Klareskog’s article in the
Lancet 2009 as an excellent update on this topic. He noted that RA could be grouped into
those with anti-CCP antibodies and those without, reflecting genetically distinct subsets
with higher disease burden in the antibody positive group. He also pointed out that
autoimmunity is an early event, with antibodies occurring years before the onset of
arthritis. He suggested that synovitis may be asymptomatic and that progression might
occur with few if any symptoms. Therefore imaging, such as the use of ultrasound, could
be important in tracking progression. He pointed out that the use of clinical and
laboratory scores could potentially predict the severity of the arthritis. Regarding
methotrexate, Professor McInnis pointed out that often doses of 25 to 30 mg per week,
given subcutaneously, were being used. He pointed out that strategies involving" treat to
target" which involved earlier intervention and use of activity scores were becoming
widely used. He did support the triple therapy of currently available methotrexate +
hydroxychloroquine + sulfasalazine as having a definite role in treating RA. He pointed
out that TNF blockers appear to slow radiographic progression of RA. He noted that 3rd
line drugs are available including abatacept, rituximab as well as tocilizumab but did not
discuss these in detail. Finally, he pointed out that there were common comorbidities of
RA, particularly cardiovascular disease and infections. In addition, RA patients often
have depression. He noted that vascular disease occurs early and RA is an independent
risk factor for cardiovascular disease, increasing the risk of myocardial infarction and
indeed death. He suggested that NSAIDs should be used with caution because of their
potential role in augmenting cardiovascular disease.
A particularly interesting presentation was by Michelle Leger, a rheumatology fellow at
the University of British Columbia. She presented a case of a patient with HIV receiving,
among other medicines, ritonavir, who had a methylprednisolone injection for bursitis
into his shoulder. The patient's provider noted that he was concerned about reports of
development of Cushing syndrome and adrenal failure with corticosteroids in some
patients receiving this drug. She reviewed the literature which indicates that ritonavir
increases bio availability of glucocorticoids, similar to a small percentage of individuals
who have increased receptor sensitivity to glucocorticoids because of a genetic mutation.
Therefore such patients receiving intra-articular corticosteroids, or inhaled steroids, may
be particularly susceptible to development of iatrogenic Cushing's syndrome and
secondary adrenal suppression. She recommended close monitoring of HIV patients on
these types of protease inhibitors who receive corticosteroid injections.
Dr. Choi gave a splendid talk on gout pointing out the increase in prevalence over last
several years attributed in part to the increased use of sweetened soft drinks containing
fructose as well as the increased prevalence of obesity in the population. He pointed out
that comorbidities for gout included the metabolic syndrome, obesity, hypertension,
coronary artery disease type II diabetes and renal insufficiency. He proposed that
lifestyle changes could be used to treat hyperuricemia, similar to strategies used to treat
hypertension. He reviewed some of Rick Johnson's publications regarding the effect of
allopurinol on lowering blood pressure in children and adolescents with hypertension.
He reviewed the evidence that hyperuricemia predisposes to development of
cardiovascular disease, diabetes and renal disease. He stopped short, however, of
recommending that asymptomatic hyperuricemia be treated with medications, beyond
simply changes in lifestyle.
Dr. Adachi gave an update on osteoporosis treatments. He pointed out that the
consequences of hip and vertebral fractures lead to an increase in mortality. He discussed
the concept of a fragility fracture, namely a fracture that occurs after fall from a standing
or sitting also for cable fractures increase the risk for subsequent fractures regardless of
the phone densities. He noted that many patients with hip fractures don't get treatment
for osteoporosis he presented an algorithm regarding fracture risk which relies both on
age as well as on the T. score. Regarding treatment he discussed what is the appropriate
amount of calcium supplementation. He reviewed a recent paper which showed that
vascular events increased in healthy older women receiving calcium supplementation.
This potentially detrimental effect should be balanced against the likely benefits of
calcium on bone. He pointed out that the total amount of calcium in the diet as well as
the supplements should be taken into account. Regarding bisphosphonate treatment, he
showed evidence that there are differences between brand and generic alendronate and
presented several case reports illustrating this. He discussed evidence for giving a drug
holiday for patients who had been on long term bisphosphonates. He concluded for many
women, discontinuation of alendronate for up to 5 years did not appear to significantly
increase fracture risk. However, women at very high risk of clinical vertebral fractures
may benefit by continuing beyond 5 years. He reviewed evidence that the zoledronic
acid reduced risk of all cause mortality by 28% over time. He debunked the fear that
bisphosphonate are tied to an epidemic of osteonecrosis of the jaw. Dr. Adachi then
discussed glucocorticoid induced osteoporosis. He pointed out that the magnitude of
increased risk of fractures was related directly to the daily dose and that the incidence of
falls also increased after starting oral steroid therapy. He reviewed strategies to prevent
and treat steroid induced bone loss and noted that a number of bisphosphonates as well as
teriparatide are effective.
Dr. Carette discussed advances in the detection and management of vasculitis. He
presented an elegant classification based on vessel size, namely large, medium, and small
vessels. Re: large vessel vasculitis, he focused on giant cell arteritis. He noted that he
recommended bilateral temporal artery biopsies which when negative provided greater
than 90% certainty of no evidence of giant cell arteritis. He also pointed out that biopsies
could remain positive on steroids for weeks after instituting treatment. Re: small vessel
vasculitis: he divided them into ANCA positive and ANCA negative small vessel
vasculitis (SVV). Regarding ANCA negative vasculitis, he pointed out there was
primary, including a HSP, cryoglobulinemic vasculitis and idiopathic; and secondary, due
to drugs, infections, connective tissue diseases, and malignancies. He gave a helpful case
report regarding a young man with a pulmonary-renal syndrome who had a positive cANCA, negative p-ANCA, and protinase-3 antibodies along with pulmonary nodules and
active urinary sediment. He discussed the concept of whether serologic tests could
replace a tissue biopsy and the fact that, in order to have confirmatory tissue biopsy, one
would need an open lung biopsy. He pointed out that when the pre-test probability
ranged from low, medium and high, in the presence of positive ANCAs, the positive
predictive value ranged from 80% to 99%. Therefore, in the case presented, his pretest
probability was high, indicating that his positive ANCA serologies could probably
replace tissue histology in this case. Finally Dr. Carette discussed the “7 habits of
effective managers for patients with ANCA related vasculitis”. He pointed out the
benefits of cyclophosphamide but emphasized strategies to reduce use of CTX to 3 to 6
months maximum. He reviewed the study published in the Annals of Internal Medicine
in 2009 entitled Pulse Versus Daily Oral Cytoxan for Induction of Remission in ANCA
Positive Vasculitis. This study showed that IV pulse CTX reduced total dose compared
to PO CTX with equivalent control of the disease but fewer side effects. He also
recommended using methotrexate rather than CTX in patients with non-life or organ
threatening vasculitis. He recommended leaving patients on low-dose prednisone (5 to
10 mg per day) rather than tapering them off completely. He reminded us of the
etanercept trial: in spite of positive case-series, the use of this drug did not stand up to
scrutiny in the well-designed controlled trial for control of Wegener's granulomatosis.
Finally he pointed out that Rituxan has a future major role in treating Wegener's
granulomatosis based on the RAVE trial results.