In recent years a number of studies have identified a connection between inflammation and various types of dementia, including Alzheimer’s disease. Meanwhile, people with rheumatoid arthritis (RA) — an inflammatory autoimmune condition — are more apt than others to develop dementia as they get older. So, can treating RA with biologic drugs that block inflammatory proteins mitigate this risk?

Research presented at ACR Convergence 2020, the American College of Rheumatology’s annual (virtual) meeting, suggests that it may be possible.

Although this study does not directly prove that biologic drugs prevent dementia, the researchers found compelling evidence that biologic drugs might reduce an RA patient’s risk of age-related memory issues.

The study, which was led by Sebastian Sattui, MD, a rheumatologist at Hospital for Special Surgery in New York City, relied on Medicare claims data that was submitted between 2006-2017. The researchers identified more than 140,000 RA patients who were enrolled in Medicare for at least one year and had no history of dementia when the study began.

During the study period, nearly 3,800 of these RA patients developed dementia. The researchers determined that the incidence of dementia was significantly higher among RA patients who were being treated with a conventional DMARD (disease modifying anti-rheumatic drug), such as methotrexate, than it was among those who were on a biologic drug like infliximab (Remicade) or etanercept (Enbrel).

Patients on any biologic drug were 17 percent less likely than those using only a traditional DMARD to have developed dementia.

There are many different classes of biologics that are approved to treat RA, including TNF inhibitors, IL-1 blockers, IL-6 blockers, IL-17 blockers, B-cell inhibitors, and T-cell inhibitors. There are also other kinds of targeted therapies called JAK inhibitors. All of these medications work differently from each other, but they act on specific immune system pathways to reduce inflammation.

Because patients in this study fared equally well regardless of which class of biologic drug they were taking, the authors suggested that a specific mechanism of action (such as targeting TNF or IL-6) is unlikely to be responsible for reducing dementia risk.

Instead, they theorized that people taking biologics — despite generally have more severe disease than those who only use conventional DMARDs — were probably benefitting from the “overall decrease in inflammation” that biologics provide.

Be Part of Rheumatoid Arthritis Research with ArthritisPower

Join CreakyJoints’ patient-centered research registry and participate in voluntary studies about managing arthritis. Learn more and sign up here.

You can participate in research studies about arthritis by using our ArthritisPower app to join our patient-centered research registry.

The COVID-19 pandemic may have changed the format of this year’s annual medical meeting of the American College of Rheumatology — it was held completely virtually — but it did not disrupt the sharing of important research that directly impacts people living with psoriatic arthritis.

The CreakyJoints team combed through hundreds of studies, attended sessions from top psoriatic arthritis experts, and asked our team of patient and physician advisors to share the updates they deemed most important.

We curated this guide to psoriatic arthritis research and trends from ACR that you should be aware of.

For more research breakthroughs from ACR Convergence 2020, check out our main guide: ACR 2020: 100+ Arthritis and Rheumatic Disease Updates Patients Must Know About.

1. Clinical trials are leading toward more personalized medicine in psoriatic arthritis

With advances in targeted therapies for psoriatic arthritis — multiple biologics as well as more oral pills on the way — “the challenge for clinicians is how to use them,” said rheumatologist Arthur Kavanaugh, MD, Director of the Center for Innovative Therapy in the Division of Rheumatology, Allergy, and Immunology at the University of California at San Diego during an ACR presentation.

Dr. Kavanagh discussed some recent head-to-head trials — in which one medication is directly compared to another — noting that this kind of research is the best way to figure out which therapies work best for which patients, reported Healio Rheumatology.

For example, in one study where the IL-17 inhibitor ixekizumab (Taltz) was compared with the TNF inhibitor adalimumab (Humira), “ixekizumab demonstrated superiority that was driven by skin response.”

Dr. Kavanaugh said that doctors need to look at which “psoriatic arthritis domains” are most important to their patient. Over time, medications will be tailored toward optimizing specific PsA domains, such as skin symptoms, axial (spine) pain, enthesitis, and more.

2. The JAK inhibitor upadacitinib (Rinvoq) is doing well for psoriatic arthritis

Already approved to treat rheumatoid arthritis, the new JAK inhibitor upadacitinib is currently being studied in other inflammatory arthritis, including psoriatic arthritis and axial spondyloarthritis. Data presented at ACR found that daily doses (either 15 or 30 mg) improved musculoskeletal symptoms, psoriasis, physical function, pain, fatigue, and radiographic progression in people with PsA.

In the phase 3 trial — the last phase before seeking FDA approval — 1,705 participants were randomized to receive either 15 mg upadacitinib daily, 30 mg upadacitinib daily, or 40 mg of adalimumab (Humira) every other week or placebo for 12 weeks. Patients already had a poor response or intolerance to at least one non-biologic disease-modifying drug.

The study used a primary endpoint called ACR20, which means a 20 percent improvement in joint pain. It was met by 71 percent of people taking the 15 mg dose of upadacitinib and by 79 percent of people taking the 30 mg dose, compared with 36 percent of people on a placebo and 65 percent of those taking adalimumab. Patients on upadacitinib also had improvements in physical function and skin clearance compared with placebo.

“Upadacitinib 15 mg and 30 mg demonstrate superior efficacy compared to placebo in treating psoriatic arthritis symptoms and signs in patients refractory to prior non-biologic DMARD therapy,” said Iain McInnes, MD, President of EULAR and Director of the Institute of Infection, Immunity and Inflammation at the University of Glasgow, in Scotland, as reported by Healio Rheumatology.

3. There was more good news for treating PsA with IL-23 medication

Interleukin-23 (IL-23) is an inflammatory protein that plays a role in psoriasis and psoriatic arthritis. Earlier this year, the biologic guselkumab (Tremfya) that inhibits IL-23 was FDA-approved for psoriatic arthritis. (It had already been approved to treat psoriasis.)

One study presented at ACR was a meta-analysis (a study that analyzes the results of other studies) of clinical trials for a large number of psoriatic arthritis treatments. It aimed to compare how guselkumab’s results would fit in. The researchers looked at a number of different outcomes, such as improvements in joint pain, skin clearance, function and disability, and more. They found that guselkumab was considered better than most other targeted treatments when it came to improving skin symptoms and was comparable to most other targeted treatments for joint symptoms, physical function, and safety.

Separate research showed that guselkumab specifically helped improve axial (spine/back pain) symptoms in people with PsA. Researchers followed people with sacroiliitis (inflammation of the sacroiliac joints, where the spine meets the pelvis) for a year and found that those who were treated with guselkumab were able to maintain improvements in back pain through one year compared with people taking a placebo.

What’s interesting about this finding, says Boston University rheumatologist Jean Liew, MD, is that a different medication that inhibits IL-23 — called ustekinumab (Stelara) — has not worked well in past clinical trials for axial symptoms.

Ustekinumab, which is approved for psoriasis, psoriatic arthritis, and inflammatory bowel diseases like Crohn’s and ulcerative colitis, works in a slightly different way from guselkumab. The difference in impact on spine symptoms “may be due to the different pathways being involved,” says Dr. Liew. This finding adds another wrinkle to the story about which therapies work best for which specific symptoms.

4. A new type of PsA medication showed promise in a preliminary trial 

The drug is called deucravacitinib and it’s considered a TK2 inhibitor. A cousin of JAK inhibitors, it’s an oral pill that acts on a specific immune system pathway to tamp down inflammation. The medication has been previously studied for psoriasis.

A study showed that, after 16 weeks, 53 percent of people receiving a 6 mg/day dose and 63 percent of people receiving a 12 mg/day met response criteria (a 20 percent improvement in symptoms, known as the ACR20), compared to just 32 percent of people who were on a placebo medication.

ACR50 responses (a 50 percent improvement in symptoms) were seen in 11 percent of the placebo group compared with 24 percent of those taking the 6 mg dose and 33 percent of those taking 12 mg.

Northwestern University rheumatologist Eric Ruderman, MD, discussed the trial results on RheumNow, saying they indicate that the medication is effective, but questioned whether it will ultimately be shown to work that much better than existing therapies, such as biologics that inhibit the inflammatory protein IL-23.

The results are from a phase 2 trial, which means the medication still needs more investigation in larger groups of patients before it can seek approval from the U.S. Food and Drug Administration (FDA). The current study included about 200 patients.

5. Carotid artery ultrasounds may help better identify heart disease risks in psoriatic patients

People with psoriatic disease have an increased risk of cardiovascular disease that is driven both by comorbidities (like obesity and diabetes) as well as inflammation and other issues directly related to the psoriatic condition itself. It’s thought that people with PsA first develop “subclinical atherosclerosis” — clogged arteries that do not cause symptoms. Detecting these changes early could help doctors and patients better manage heart disease risk factors.

A study from a team of researchers from Mexico found that using a non-invasive ultrasound to measure the thickness of the carotid artery in the neck could help better identify PsA patients with cardiovascular risk factors. Researchers conducted ultrasounds on 69 PsA patients and 69 controls who were matched for age and comorbidities, but did not have PsA. They found there as was a greater prevalence of thickness of the carotid artery and more plaque in people with PsA than in the control group.

The researchers concluded that “patients with psoriatic arthritis have a higher cardiovascular risk, as proven by the increased cIMT found on carotid ultrasound results” and that it is “opportune to perform a carotid ultrasound in patients with PsA to attain an optimal management of the disease.”

6. Ultrasounds could help differentiate psoriatic patients who also have fibromyalgia 

When people with inflammatory arthritis also have fibromyalgia (which is common), the inflammatory arthritis can be harder to treat and manage. Thus, it’s important to know when fibromyalgia may be contributing to hard-to-treat symptoms rather than the inflammatory arthritis. A team of Israeli and Canadian researchers did full-body ultrasounds on 156 psoriatic arthritis patients — including joints, tendons, and entheses — looking for signs of inflammation of the joint fluid (synovitis), around the tendons (tendosynovitis), and of the entheses (enthesitis). The patients also completed surveys about their symptoms, which helped classify them as having or not having fibromyalgia.

The researchers found that while people with fibro and PsA had worse scores on clinical measures of pain compared to PsA patients without fibro, the ultrasound results were similar between the two groups.

The researchers believe their results show that ultrasounds have “significant additional value” in assessing disease activity in PsA patients with fibromyalgia. This could help doctors figure out how to tailor treatments for people who have both conditions.

 7. ‘Residual’ symptoms of PsA are common in people who are deemed to be in very low disease activity

Many PsA patients know that just because you’re considered to be in low disease activity doesn’t mean you feel well. Now data from a team of researchers at the University of Pennsylvania, New York University, Northwestern University, the University of Utah, and the Cleveland Clinic demonstrates this. Researchers surveyed 244 PsA patients who started a new PsA therapy and completed a series of questionnaires about their symptoms. Doctors assessed disease activity with counts of swollen and tender joints as well as assessing enthesitis (inflammation where tendons and ligaments meet bone, such as at the Achilles heel).

The researchers found that 47 percent of people who were considered by their doctors to be in very low disease activity had at least one residual symptom, compared to 85 percent of people who were not considered to be in low disease activity who had at least one residual symptom. The most common lingering symptoms were fatigue, spine pain, peripheral joint pain/swelling, stiffness, disrupted sleep, and tenderness to touch.

More than 10 percent of people with very low disease activity reported difficulty with daily function, work, and skin symptoms.

This study shows that “despite effective therapy, many patients continue to have active symptoms,” says study coauthor and rheumatologist Alexis Ogdie, MD, Associate Professor of Medicine at the Hospital of the University of Pennsylvania.

The researchers concluded that “further studies are needed to develop comprehensive, evidence-based, patient-focused treatment plans to address these residual symptoms.”

8. PsA patients and providers have different perspectives on the prevalence of fatigue

Ask anyone with psoriatic arthritis about fatigue, and they’ll likely share that it is a huge burden. Many PsA patients consider fatigue as big or bigger a problem than joint pain or skin plaques. An interesting study asked a group of international PSA patients and their providers (932 pairs in all) to fill out surveys about different aspects of their disease. Patients completed surveys on fatigue, work productivity, disability, and more. Doctors answered questions about their patients’ disease and whether or not the patients had fatigue.

They found that while 81 percent of patients reported fatigue, only 28 percent of providers said their patients had fatigue.

Researchers, led by rheumatologist Jessica Walsh, MD, Instructor at the University of Utah School of Medicine and George E. Wahlen Veteran Affairs Medical Center, concluded that such discrepancies “between patient and physician reports of fatigue suggest that physicians may not be aware of the extent to which patients experience fatigue.”

9. PsA patients and providers also have different perspectives on the prevalence of anxiety and depression

Some of the same researchers conducted a similar study seeking to understand whether patients and providers report comparable rates of mental health issues like anxiety and depression in psoriatic arthritis patients. After collecting data on 688 patient-physician pairs, they found that doctors reported anxiety and/or depression in 14 percent of patients, but 37 percent of patients self-reported anxiety or depression.

It also seems that doctors may not be aware of the degree to which PsA patients are struggling with anxiety and/or depression.

10. A majority of PsA patients have an ‘unacceptable’ level of disease activity, which is linked with more depression and challenges with social activities 

Although treatments for psoriatic arthritis have proliferated in recent years, many people do not achieve remission. Having ongoing disease activity takes a toll on many different aspects of patients’ lives, including an association with more depression and challenges with social interactions.

Researchers, led by Dr. Ogdie, sought to understand patient perceptions around “unacceptable” symptoms, according to a survey called the PsAID9, which asks about pain, fatigue, skin problems, work and leisure activities, sleep disturbance, and more. A survey was completed by 1,570 members of the National Psoriasis Foundation.

Of those who had a self-reported diagnosis of PsA and completed the PsAID, 60 percent reported an unacceptable level of disease activity. Having unacceptable disease activity was also associated with depression and challenges participating in social activities.

The good news was that “being monitored by a dermatologist or rheumatologist was associated with an increased likelihood of being in a patient acceptable symptom state,” the researchers found.

11. There’s an increased focus on identifying people with psoriasis at an increased risk of developing psoriatic arthritis

Identifying people with psoriasis who, for various reasons, could be at increased risk of developing psoriatic arthritis could provide a unique opportunity to implement preventive strategies to thwart that progression. This could include treating psoriasis more aggressively with medication and/or making lifestyle changes, such as losing weight if needed.

More research is needed to understand how progression from psoriasis to psoriatic arthritis can be stopped, but in order to do that research, there must be agreement on which kinds of patients are at an increased risk.

So a team of psoriatic experts has been studying how to classify and identify such “pre-clinical” PsA patients. In research presented at ACR, they shared some risk factors in psoriasis patients that they agreed are linked to an increased risk of PsA:

• Obesity
• Presence of arthralgia (joint pain)
• Severe psoriasis
• History of uveitis (eye inflammation)
• Nail psoriasis
• Scalp psoriasis
• First-degree relative with psoriatic arthritis

12. Delays in getting diagnosed with psoriatic arthritis are common, even in people with joint pain symptoms 

Researchers led by Paras Karmacharya, MD, a rheumatologist at the Mayo Clinic College of Medicine in Rochester, Minnesota, analyzed data on 162 people who were diagnosed with psoriatic arthritis between 2000 and 2017. They found that it took more than two years from the time joint pain symptoms started for people with psoriatic arthritis (PsA) to be diagnosed with this condition.

People who were under age 40 when symptoms began, those with a higher body mass index (BMI), and those with enthesitis (inflammation in the spot where ligaments attach to bones) were more likely to experience a delay in diagnosis. Read more here about the findings.

13. Looking at patients’ medical histories before they get diagnosed with psoriatic arthritis could provide clues that accelerate diagnosis for others

What kind of health care journey do patients follow on the route to getting diagnosed with PsA? Researchers looked at a large insurance claims database to better understand the kinds of medical codes that were logged in the six years prior to people being diagnosed with psoriatic arthritis, comparing 13,661 people who ultimately got diagnosed with PsA with controls who were not diagnosed with PSA.

They found that people who were ultimately diagnosed with PsA were more likely to have a code for psoriasis (60 percent compared to 2 percent of controls) in their medical record. People who were ultimately diagnosed with PsA but did not have a prior code for psoriasis were more likely to have been codes for other forms of arthritis, such as osteoarthritis or rheumatoid arthritis, suggesting this is an area where misdiagnosis is common.

As patients got closer to getting diagnosed with PsA, codes for enthesitis, back pain, and psoriasis became more common, which indicates these are PsA clues doctors and patients should pay attention to. 

Researchers also observed that the type of provider patients saw had a big impact on their pre-PsA diagnoses. Dermatologists were less likely than other providers to enter codes for arthritis and musculoskeletal issues, while rheumatologists were unlikely to code for psoriasis but had a fairly even distribution across different types of arthritis. 

In the end, PsA was most commonly diagnosed by rheumatologists (40 percent) but was diagnosed in 22 percent and 7 percent of cases by general practitioners and dermatologists, respectively.

14. A smartphone app could help diagnose psoriatic arthritis in remote settings

A preliminary study is investigating whether smartphone technology could assist doctors in diagnosing conditions like psoriatic arthritis in telehealth settings.

An app being developed incorporates sensor-based measurement tools that could measure changes in certain aspects of psoriatic arthritis symptoms. For example, the app uses a gyroscope to measure arm rotation and what happens when a user opens a jar. It measures users’ gaits while walking to look for problems with symmetry. It takes pictures of fingers and toes to check for symptoms like dactylitis (or swelling of the digit such that it resembles a sausage).

Researchers are currently testing the app in people with PsA and healthy controls to how the app records different results in people with PsA and without, and whether these differences are significant enough to predict PsA symptoms in people who are not yet diagnosed. Initial results suggest that the measurements so far can distinguish some features of PsA, but testing a bigger group of patients is needed.

The authors note that if ultimately validated, “these and other tools may provide for remote self-assessment when clinical visits cannot be performed.” Such technology could also help study disease progression and assess patients’ response to treatment.

You Can Participate in Psoriatic Arthritis Research Too

If you are diagnosed with psoriatic arthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining CreakyJoints’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centered research registry for joint, bone, and inflammatory skin conditions. Learn more and sign up here.

You can participate in research studies about arthritis by using our ArthritisPower app to join our patient-centered research registry.

COVID-19 may have changed the format of this year’s annual medical meeting of the American College of Rheumatology — it was held completely virtually — but the pandemic did not disrupt the sharing of important research that directly impacts people living with osteoarthritis (OA).

The CreakyJoints team combed through hundreds of studies, attended sessions from top osteoarthritis experts, and asked our team of patient and physician advisors to share the updates they deemed most important.

We curated this guide to osteoarthritis research and trends from ACR you should be aware of.

For more research breakthroughs from ACR Convergence 2020, check out our main guide: ACR 2020: 100+ Arthritis and Rheumatic Disease Updates Patients Must Know About.

1. Warfarin could increase the risk of needing a hip or knee replacement

Warfarin is a drug that is often prescribed to prevent blood clots — especially in people with the heart condition atrial fibrillation — but it may pose a risk to your joints if you have osteoarthritis, compared with other types of medications that prevent blood clots.

Warfarin works by reducing the action of vitamin K, which plays a role in helping your blood clot. However, vitamin K is also important for bone and cartilage health.

A team of researchers from Boston University Medical School and Erasmus Medical Center in the Netherlands looked at a group of people who had knee and hip replacements and were taking either warfarin or other anti-clotting medications (because they had atrial fibrillation) and compared them with a control group of patients taking these medications but did not have joint replacement surgery. The researchers found that, after adjusting for potential cofounders, warfarin users had 1.57 times higher chances of having hip or knee replacement than people taking other blood-clotting medications.

This research suggests that it’s important to have adequate levels of vitamin K to help limit the progression of osteoarthritis. Read more here about the findings.

2. Knee steroid injections do not seem to increase the need for earlier knee replacement surgery 

Corticosteroid injections in the knee are a common pain treatment for osteoarthritis. But past research has suggested that getting such injections can actually worsen OA disease progression. However, those findings have been controversial and disputed, in part because patients in the studies already had advanced knee OA, which is itself a risk factor for disease progression.

Now new research suggests that steroid injections do not make people more likely to need knee replacement sooner. Researchers used two large group studies of knee osteoarthritis patients who received either corticosteroid or hyaluronic acid injections (a different kind of OA treatment) to review rates of radiographic progression (joint damage you can see on X-rays) and total knee replacement surgery.

People who got corticosteroid injections did not have a higher risk of radiographic progression or needing a total knee replacement (two signs of worsening knee osteoarthritis) compared to people who got hyaluronic acid injections.

“Patients and clinicians should see this study and feel reassured that these injections are not causing progression of osteoarthritis or earlier total knee replacement,” study coauthor Justin J. Bucci, MD, Assistant Professor of Medicine at Boston University School of Medicine, said in a press release. Learn more here about the findings.

3. Methotrexate may help reduce inflammation and damage in knee osteoarthritis 

Methotrexate is a disease-modifying drug commonly used to reduce inflammation in inflammatory conditions like rheumatoid arthritis or psoriatic arthritis. But could it also be effective for knee osteoarthritis, which is not driven by systemic inflammation?

Researchers at SSKM Hospital in Kolkata, India compared oral methotrexate to a placebo treatment with glucosamine (a common arthritis supplement taken for pain relief) in adults with knee osteoarthritis.

Patients with knee osteoarthritis with evidence of inflammation in the joint showed significant improvements on WOMAC scores (a measurement of physical function) and decreases in levels of erythrocyte sedimentation rate and C-reactive protein (measures of inflammation in the blood) after three months of taking oral methotrexate. Meanwhile, those on glucosamine showed no significant improvement in these measures of inflammation and function.

The results of this study suggest that methotrexate can be an effective intervention for people with knee osteoarthritis who experience pain and inflammation. Read more here about the findings.

4. The biologic medication tocilizumab (Actemra) did *not* improve hand osteoarthritis

Meanwhile, research on a different disease-modifying medication, tocilizumab (Actemra), showed that the medication did not work any better than a placebo for hand osteoarthritis, reported French researchers.

Patients who were randomized to get two infusions of tocilizumab four weeks apart did not have any significant differences in such measures as self-reports of pain, the number of painful or swollen joints, or duration of morning stiffness compared with people who got a placebo treatment.

It was hoped that the medication, which targets an inflammatory protein called interleukin-6 (IL-6) and is approved to treat autoimmune conditions like rheumatoid arthritis and juvenile idiopathic arthritis, might also work in osteoarthritis by reducing aspects of inflammation that can play a role. But this study did not show a benefit and — what’s more — there were slightly more adverse events in the people who took tocilizumab compared to the placebo.

5. The biologic medication tanezumab shows lasting benefits in pain reduction

Approved medications for osteoarthritis are limited, so new potential therapies draw a lot of excitement. One treatment that has been in the spotlight for a few years is tanezumab. It’s an injection (placed in the knee or hip) that inhibits a protein called nerve growth factor, which is thought to play a role in OA pain. This medication works very differently from other pain relief options, such as NSAIDs or opioids. If shown to be effective and safe, it would be a welcome tool in the OA treatment arsenal.

A number of studies on tanezumab were shared at this year’s ACR meeting, and the news seems mostly promising. One study led by Thomas Schnitzer, MD, of Northwestern University, looked at improvements in OA pain after 16 weeks of getting the medication. It found that a significantly greater proportion of patients who got tanezumab had a “clinically important improvement” in pain compared with people who got a placebo.

A different study, led by Boston University rheumatologist Tuhina Neogi, MD, followed patients who got tanezumab over time to see whether the benefits lasted. The medication continued to show benefits in pain reduction that lasted through the study period (up to 56 weeks).

One hitch with tanezumab was that in trials years ago, “they started seeing rapidly progressive joint destruction in people who received these,” explains Boston University rheumatologist Jean Liew, MD (who was not involved with the research). “The FDA put a partial hold on the trials in 2015 and investigated whether this joint destruction was due to rapid progression of the underlying OA that people had when they entered the trials, or if the medication was causing it.” After further investigation, tanezumab trials were able to resume with more vigorous screening of participants (so people deemed at higher risk of this rapidly progressive joint destruction would not be able to enter the trial). Since higher doses of tanezumab and combinations of tanezumab with NSAIDs seemed to put people at higher risk (or at least was associated with more of these adverse joint events), the trials after 2015 have been restricted to tanezumab alone and at lower doses (compared to placebo).

In these newer trials, they haven’t seen an increase in reports of joint safety events, Dr. Liew notes. The medication is not yet FDA-approved.

If it gets approved, Dr. Liew says it will likely be used for people with significant pain after trying other treatments. “It may be an option for people who have not had good enough pain relief from other modalities and are not going to have joint replacement surgery.”

6. Bariatric surgery can help improve knee function and delay knee replacement

Obesity is a known risk factor for osteoarthritis. Many people who are obese and require knee replacement surgery are counseled to lose weight first, which helps reduce the risk of post-surgery complications. However, weight loss is often difficult and bariatric surgery may be recommended.

A team of researchers is studying people who receive bariatric surgery to understand the impact on knee pain and function compared with obese patients who have knee replacement surgery without weight loss surgery first.

In initial findings, people who underwent bariatric surgery had comparable improvements in certain measures of pain and knee function compared with people who had knee replacement surgery. The researchers concluded that “bariatric surgery may result in modest improvements in knee outcomes and may eventually delay the need for a [knee replacement].”

Rheumatologist Janet Pope, MD, Professor of Medicine in the Division of Rheumatology and Epidemiology and Biostatistics at the University of Western Ontario in Canada, said in a video on RheumNow that this research shows “if you get bariatric surgery, your knee OA does improve a bit, so that’s another benefit for those patients.”

7. The severity of hand osteoarthritis is linked with overall body fat

Over the last four years, researchers at New York University established a registry of people with hand osteoarthritis (and not other forms of hand joint pain, such as rheumatoid arthritis psoriatic arthritis, or lupus) to understand factors that contribute to the prevalence and severity of hand OA. Researchers collect patients’ questionnaires about pain, stiffness, and function; hand X-rays if available; and blood and urine samples.

In an initial analysis of the 170 people enrolled so far, researchers found that people with a body mass index (BMI) greater than 30 (which is considered obese) had more hand pain, stiffness, and disability compared to people with a healthy body weight (BMI less than 25).

They also found that women reported significantly more disability and a higher average number of joints affected than men with similar ages and BMI. A small subgroup of likely perimenopausal women (ages 48-54) reported more pain and disability than their older counterparts, despite a lower average BMI and fewer hand joints affected by OA.

The study authors suspect that “hormonal influences during the perimenopausal state may increase [hand osteoarthritis] symptoms during those years.” More research is needed to understand the role that weight and body fat may play in the onset and severity of hand OA.

8. Many osteoarthritis patients are at risk for adverse events from non-steroidal anti-inflammatory medications (NSAIDs)

 Non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen (Advil) and naproxen (Aleve), as well as prescription versions, are pain relief staples for osteoarthritis. However, even though these medications are commonly used, they have side effects that patients need to know about — including gastrointestinal bleeding and an increased risk of cardiovascular and kidney function issues.

For people with certain health issues, these potential side effects could be serious enough to “contraindicate” NSAIDs (meaning, that people shouldn’t take them) or at least make sure they watch their usage closely.

But research suggests that many people with hip and knee osteoarthritis have risk factors that could increase their risk for NSAID-related adverse events. Researchers studied an insurance claims database and identified 218,349 people with hip or knee OA. They found that more than one-third had risk factors that could increase their risk for NSAID-related adverse events. Of these, approximately 50 percent of people had evidence of prescription NSAID use that was inconsistent with safety recommendations.

The study authors concluded that “these results emphasize the need to consider the risks associated with NSAIDs and to individualize osteoarthritis management strategies to mitigate the risk of NSAID-related adverse events.”

If you take NSAIDs regularly and have not talked to your doctor about potential side effects, it’s a good idea to check in and make sure your dosage is safe given your personal health history.

9. ‘Patient readiness’ helps improve the results from knee replacement surgery

 For many osteoarthritis patients, coming to the decision that joint replacement surgery is needed isn’t always easy. There could be some denial that the pain and disability has gotten so bad as to necessitate surgery, or concerns about the procedure or recovery process. But being mentally prepared for joint replacement seems to impact how well you’ll feel and function afterward, report a team of Canadian researchers.

They asked people who were about to undergo knee replacement surgery to fill out surveys ahead of time that assessed “patient readiness,” how willing people were to undergo surgery, and how they coped with arthritis pain. Researchers then assessed participants a year after their procedures to see whether or not they had a good outcome (defined as improvement in knee symptoms and general satisfaction with the results).

Of 1,272 participants, 79 percent reported a good knee replacement outcome. The patients whose assessments showed that they were “more psychologically ready” had higher odds of having a good outcome. The researchers call for incorporating these kinds of questionnaires into the decision-making process for patients and doctors when discussing surgery as an osteoarthritis treatment.

10. Walking for exercise may actually prevent the progression of knee osteoarthritis 

Walking is widely recommended as low-impact exercise for people with knee osteoarthritis. It can also help with weight management, which is important for reducing stress on arthritic knees. Now research shows that people with knee arthritis who walk for exercise may actually have fewer painful symptoms and less structural damage over time.

Researchers studied 1,203 participants, taking X-rays of their knees at the start of the study and then four years later. About three-quarters of people said they walked for exercise. New knee pain was less common in people who walked and walking was associated with less structural progression of OA (as measured by looking at changes on X-rays) in patients with certain types of knee alignment.

The study’s authors concluded that “these findings support that walking for exercise should be encouraged for most people with knee OA.”

You Can Participate in Osteoarthritis Research Too

If you are diagnosed with osteoarthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining CreakyJoints’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centered research registry for joint, bone, and inflammatory skin conditions. Learn more and sign up here.

You can participate in research studies about arthritis by using our ArthritisPower app to join our patient-centered research registry.

COVID-19 may have changed the format of this year’s annual medical meeting of the American College of Rheumatology — it was held completely virtually — but the pandemic did not disrupt the sharing of important research that directly impacts people living with gout.

The CreakyJoints team combed through hundreds of studies, attended sessions from top gout experts, and asked our team of patient and physician advisors to share the gout updates they deemed most important.

We curated this guide to gout research and trends from ACR that you should be aware of.

For more research breakthroughs from ACR 2020, check out our main guide: ACR 2020: 100+ Arthritis and Rheumatic Disease Updates Patients Must Know About.

 1. Diet plays only a small role in elevated uric acid levels

Gout experts have long known this, but it’s important to see data that backs up the fact that dietary changes can only go so far in reducing uric acid levels. (Uric acid is a normal waste product. When high levels accumulate in the blood, it can crystallize in the joints, leading to painful gout attacks.)

An international team of gout researchers sought to study the relative contributions of different gout risk factors on lowering uric aid levels, including certain genetic variations, diet, weight (BMI), alcohol intake, the use of diuretic medications, sex, and age.

What they found: “Changes in uric acid related were very small compared to the changes you can get with a uric acid-lowering medication such as allopurinol,” says CreakyJoints advisor Theodore Fields, MD, a gout expert and rheumatologist at Hospital for Special Surgery in New York City. “The changes with allopurinol were 10 times greater than with diet.”

This demonstrates the importance of taking medication to lower high uric acid levels and not assuming or hoping that diet changes alone can treat high uric acid.

This is also good news for gout patients who find it difficult to follow a very restrictive low-purine diet.

“I feel that we can allow our patients to have a normal diet, within reason, and [optimize] the dosing of their urate-lowering therapy to achieve that goal,” said Ireland-based rheumatologist Richard Conway on RheumNow. “We have highly effective treatments for reducing [uric acid] available … an overly restrictive diet can take much of the joy from life and the benefits may not justify the sacrifice.”

2. A diet high in fast food increases uric acid levels (but because of weight gain)

In other research on the role of diet in gout, researchers from Massachusetts General Hospital reviewed data from a group of 3,122 people who were being studied over a long-term period mainly to assess cardiovascular risk factors. This group filled out surveys about their diets and had regular lab tests and doctor’s visits. The researchers classified their diets based on how often they ate fast food and looked at uric acid levels at the beginning of the study and then 15 years later. People who ate the most fast food had a greater increase in uric acid levels over the study period than people who ate the least, “but the increase was relatively small,” notes Dr. Fields. “The authors suggested that the uric acid increase may be more related to weight gain than specific foods.”

This research, along with the study above, “supports the need for medication in most gout patients,” says Dr. Fields.

 3. The uric acid-lowering drug febuxostat might be safer than previously thought 

When people with gout need to take medication to preventively lower uric acid levels (high uric acid in the blood is what triggers gout flares), they are commonly prescribed a drug called allopurinol. Another medication that works similarly to allopurinol called febuxostat (Uloric), received a black box warning from the U.S. Food and Drug Administration (FDA) last year because a study found that there was a higher cardiac and overall death rate for people on febuxostat than on allopurinol.

However, there were a few problems with that study (called the CARES trial) that called the results into question. “Rheumatologists were skeptical of the CARES conclusions overall, and several other studies had not found a cardiovascular risk of febuxostat,” says Dr. Fields.

At ACR this year, the results from a different study (called the FAST trial) did not show any difference in the death rates between people taking febuxostat compared to allopurinol.

In this study, there were more than 6,128 gout patients already taking allopurinol; then half were randomized to start febuxostat instead. They were then followed for five years. Both groups had comparable withdrawal rates (people who stopped taking the medication) of around 5 percent, roughly the same number of gout flares, and no differences in adverse events.

“This research should give some peace of mind to patients on febuxostat,” says Dr. Fields. “We will likely still tend to use allopurinol before febuxostat, but for people on febuxostat we really don’t have much reason to be concerned about its cardiovascular safety relative to allopurinol.”

4. ‘Immunomodulation’ helps make pegloticase, a medication for chronic gout, much more effective

Uric acid-lowering medications such as allopurinol and febuxostat are staples of gout treatment, but for some patients these medications don’t work well enough to reduce gout flares, or they’re not tolerated.

At this point, people may be good candidates for an intravenous medication called pegloticase (Krystexxa), which can dramatically lower uric acid levels over a short time. However, pegloticase is only effective about 40 percent of the time because many people form antibodies to it. This causes the medication to stop working for them or causes them to have reactions to it, says Dr. Fields.

At ACR this year, “a number of studies addressed a new strategy to prevent people from forming antibodies to pegloticase by using a medication with the pegloticase that suppresses antibody formation,” says Dr. Fields. “The goal is to have a medication that decreases antibody formation but still has a low risk of side effects.”

Three medications studied for this purpose are commonly used to treat other rheumatic conditions such as rheumatoid arthritis and lupus. They are methotrexate, azathioprine (Imuran), and mycophenolate mofetil (Cellcept).

“These studies were small, but all suggested that the medications added to pegloticase all had a low risk of side effects during the treatment period, generally three to six months.  All of them increased the effectiveness of the pegloticase,” says Dr. Fields.

For example, in one study, 68 percent of people who were given mycophenolate along with pegloticase were able to maintain low uric acid levels (less than 6 mg/dL) after 24 weeks compared with 30 percent of people who got a placebo drug with pegloticase.

“This is hopeful data that using this strategy of combined medications can allow more patients with severe gout to respond to pegloticase,” Dr. Fields says.

On RheumNow, rheumatologist Alexa Meara, MD, described the findings as a “shift in gout management and uric acid lowering therapy.” She also noted “there might be further benefits in using such concomitant immunosuppressants since these drugs are also anti-inflammatory.  Maybe gout should be also approached to treat the inflammation not just to decrease the serum uric acid.”

5. Gout is an independent — and underestimated — risk factor for cardiovascular disease

Cardiovascular disease is common in people with gout, but it’s unclear what’s behind the risk. Is it that people with gout have health issues that are also linked to cardiovascular disease, such as obesity, high blood pressure, and diabetes? Or is gout a separate risk factor for cardiovascular disease?

New Zealand researchers shared data that concluded that gout is an independent risk factor for cardiovascular disease. They studied a group of 441,723 people who had a cardiovascular risk assessment during a primary care doctor visit. Of these, 23,229 people met the definition of having gout. When researchers looked at the number of cardiovascular events (such as heart attacks) within five years of the assessment and compared rates among people with gout and people without, they found that women with gout had a 24 percent increased risk of cardiovascular events and men with gout had a 21 percent increased risk.

What’s more, they found that traditional heart disease risk assessments underestimated cardiovascular events in gout patients, especially in women.

Research like this is important for gout patients and providers to be aware of in order to manage other heart disease risk factors (such as cholesterol or high blood pressure) and ensure patients get appropriate heart disease screening and treatment.

6. What’s the link between gout and type 2 diabetes? New research emphasizes the role of insulin resistance

Studies that observe groups of people with gout have found links between type 2 diabetes and gout, but it’s not clear whether gout may cause diabetes, diabetes may cause gout, or there’s some other confounding factors at play. Researchers from Massachusetts General Hospital did an analysis of genetic variations — some that were strongly linked to high uric acid levels and others that were linked with type 2 diabetes and related metabolic issues, such as insulin resistance.

They learned that genetically raised insulin levels — a precursor to type 2 diabetes — seems to play a role in causing high uric acid levels, not the other way around.

This could mean that treatment plans that focus on lowering insulin resistance could, in fact, also lower uric acid levels — and gout. However, the opposite may not be true. Treatments that target lowering uric acid might not lower the risk of type 2 diabetes.

7. Gout patients who visit the emergency department for flares miss an opportunity for better gout treatment

A gout flare can be one of the most suddenly painful experiences — many patients say even brushing their toes against a bedsheet is intolerable. It’s no wonder, then, that many people visit the emergency department to get help for a gout flare. But data from Rutgers researchers in New Jersey found that nearly 30 percent of gout patients are discharged from the emergency department without an anti-inflammatory medication (which is the first-line choice for treating a flare). As well, initiation of uric acid-lowering therapy, such as allopurinol and febuxostat, was rare.

“Treatment of gout in the [emergency department] is sub-optimal and often does not follow established guidelines,” the study authors concluded. If you visit the emergency department for a gout flare, that’s a sign you should be following up with the primary care doctor who treats your gout (such as an internist or rheumatologist) to look at your treatment and decide whether a change is needed.

8. It’s important for people with gout to continue uric acid-lowering medications when hospitalized

Researchers at Abington Hospital in Pennsylvania looked at the medical charts of gout patients who were hospitalized for reasons other than gout and were taking the uric acid-lowering medication allopurinol outside of the hospital. People whose allopurinol was stopped during their hospital stay (the reasons for this are unclear) were 14 times more likely to have a gout flare than people who were able to keep taking the medication while hospitalized.

“Understanding the role of continuation of [uric acid-lowering therapy] in the inpatient setting is of paramount importance in decreasing the risk of gout flare in hospitalized patients,” the study authors concluded.

9. Gout is often negatively portrayed in movies and TV shows

Researchers from New Zealand and Germany analyzed depictions of gout in film and TV since 1990 using databases such as Internet Movie Database (IMDb) and others. They found that gout was often portrayed as “as a humorous and embarrassing condition, caused by dietary indulgence,” according to the study authors. Overindulgence of food and alcohol was the most commonly depicted cause, while depictions of biological causes were infrequent. When gout management was discussed, there was an emphasis on changes in diet and pain relief — and only one mention of uric acid-lowering therapy.

These kind of media messages “can influence patients to blame themselves for their gout,” says Dr. Fields. “We know that gout is largely a genetic disease and that it has excellent treatments, but if people think it’s all because of what they eat and drink they may not seek out care or may not stay on their medications.”

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The antimalarial drug hydroxychloroquine does not appear to affect heart rhythm in lupus patients, even if they have chronic kidney disease.

That’s according to new research presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology, in which researchers studied data of 194 lupus patients from an electronic medical records database at NYU Langone Health from March 2012 to May 2020.

Systemic lupus erythematosus (SLE or lupus) is an autoimmune disease that causes systemic inflammation that can affect multiple organs, including the skin, joins, kidneys, tissue lining the lungs, heart, and brain.

Chronic kidney disease is a complication of lupus that can be associated with higher levels of hydroxychloroquine, which is a commonly prescribed medication for lupus.

Hydroxychloroquine is considered a “first-line” therapy for lupus, which means it is prescribed to most newly diagnosed patients. It is typically well-tolerated and considered low-risk for side effects.

While hydroxychloroquine can cause a delay in the heart’s electrical conduction system, previous research in people with lupus shows there is not a serious risk of abnormal heart rhythm.

That said, there has been a concern that lupus patients with reduced kidney function may be more likely to experience heart side effects from higher levels of hydroxychloroquine.

The QTc interval measurement on an electrocardiogram (EKG) is a way to assess the heart’s electrical signaling. It measures the time it takes the heart to contract and relax with each heartbeat. People who have longer QT intervals have a higher risk for heart arrhythmias, or irregular heartbeats, which would be life-threatening.

“Hydroxychloroquine use increased during the COVID-19 pandemic, with some contradictory reports regarding its cardiac safety,” the study’s coauthor, H. Michael Belmont, MD, Professor of Medicine at New York University Grossman School of Medicine and codirector of NYU Lupus Center, said in a press release. “It is important to provide reassurance to lupus patients who need to take this medication regularly and for long periods that it is generally safe and without consequential risk for serious heart toxicity.”

In the study, researchers collected data on the 194 patients’ EKG results, including the QTc intervals from their first and final EKGs.

Prolonged QTc intervals are considered more than 450 milliseconds for men and more than 470 milliseconds for women, while severe prolongation is more than 500 milliseconds. Researchers also tracked patients’ levels of creatinine (a waste product that increases in your body when your kidneys aren’t functioning properly), demographics, and whether or not they had CKD.

The researchers found there was no significant difference in QTc intervals based on whether or not people were taking hydroxychloroquine.

When researchers looked specifically at lupus patients with chronic kidney disease, they found that this group was more likely to have prolonged QTc when compared to those without chronic kidney disease, but they did not have any significant differences in their mean QTc intervals based on their hydroxychloroquine use.

What’s more, none of these patients had documented tachyarrhythmia (a more rapid than normal heart rate) or Torsades de pointes (Tdp), a life-threatening arrhythmia.

“The findings of this study can provide some comfort to lupus patients, including those with chronic kidney disease, that hydroxychloroquine is not likely to produce serious heart arrhythmias,” said Dr. Belmont. “Future studies could investigate these observations in even larger numbers of patients and include a prospective examination of QTc intervals in patients before and after starting the medication to provide even further assurance of drug safety.”

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Diagnosing a chronic inflammatory condition as early as possible is one of the best ways to stop or slow its progression. Yet it often takes people many years to get the right diagnosis, despite having red-flag symptoms.

In a recent study presented at ACR Convergence 2020, the American College of Rheumatology’s annual meeting, researchers found that it took more than two years from the time joint pain symptoms started for people with psoriatic arthritis (PsA) to be diagnosed with this condition.

The researchers, led by Paras Karmacharya, MD, a rheumatologist at the Mayo Clinic College of Medicine in Rochester, Minnesota, analyzed data on 162 people who were diagnosed with psoriatic arthritis between 2000 and 2017.

According to their findings, it took more than half of PsA patients at least two years between “disease onset” — defined as when they first reported joint symptoms to their doctor — and getting an official diagnosis of PsA.

The researchers found that people who were under age 40 when symptoms began, those with a higher body mass index (BMI), and those with enthesitis (inflammation in the spot where ligaments attach to bones) were more likely to experience a delay in diagnosis.

“Younger patients are more likely to dismiss their symptoms, not report joint symptoms, or not be aware of joint inflammation,” Dr. Karmacharya explains. Meanwhile, “obese patients often have other joint conditions that could potentially explain their joint symptoms, such as osteoarthritis or gout.” This could also lead to a delay in diagnosis.

While having enthesitis — such as inflammation in the Achilles tendon near the heel — might seem like it should speed up a psoriatic arthritis diagnosis, it’s actually not a very common symptom of inflammatory arthritis (aside from spondyloarthritis), says Dr. Karmacharya. Additionally, patients and doctors tend to assume that pain and stiffness in the heel, knee, hip, elbow is caused by overusing those joints (such as a workout injury).

Dr. Karmacharya adds that having to wait a long time to see a specialist might be another important factor in diagnosis delays. People who are unsure if they could have psoriasis, including those with a scalp condition known as sebopsoriasis, should consult a dermatologist, whereas those with joint symptoms should see a rheumatologist to sort out whether they have PsA or another rheumatic or musculoskeletal disease.

Interestingly, people who had psoriasis before their joint symptoms began were only slightly more likely than others to get their PsA diagnosis in less than two years. The vast majority of people with PsA develop psoriasis, characterized by scaly skin plaques, years prior to developing arthritis.

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New research shows that the disease-modifying drug hydroxychloroquine does not cause significant differences in measures of heart rate (QTc length or prolonged QTc) in people with rheumatoid arthritis or systemic lupus erythematosus (SLE).

Rheumatoid arthritis, a type of autoimmune arthritis, occurs when the immune system is overactive, causing inflammation, pain, and swelling in joints throughout the body.

Lupus is another autoimmune disease that causes inflammation all over the body and usually affects multiple organs, including the skin, kidneys, lungs, and heart.

Hydroxychloroquine is a staple treatment for lupus patients. Rheumatoid arthritis patients may also take it alone or with other treatments.

There have been some concerns about hydroxychloroquine’s heart-related side effects in terms of the prolongation of QTc (the amount of time it takes the heart to contract and relax) and the development of arrhythmia (irregular heartbeats).

The QTc interval measurement on an electrocardiogram (EKG) is a way to assess the heart’s electrical signaling. It measures the time it takes the heart to contract and relax with each heartbeat. People who have longer QT intervals have a higher risk for heart arrhythmias, or irregular heartbeats, which can be life-threatening.

Prolonged QTc intervals are considered more than 450 milliseconds for men and more than 470 milliseconds for women, while severe prolongation is more than 500 milliseconds.

A new study presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology assessed QTc length in lupus and rheumatoid arthritis patients and its link to hydroxychloroquine use.

“Hydroxychloroquine remains the foundation of disease-modifying antirheumatic drug therapy in rheumatic disease patients,”  one study’s coauthor Elizabeth Park, MD, rheumatology fellow at Columbia University Irving Medical Center, said in a press release. “Given recent concerns surrounding hydroxychloroquine’s use in COVID-19 patients and subsequent arrhythmic events, we wanted to examine the associations between its use and the QTc length on electrocardiograms in a large, asymptomatic cohort of rheumatoid arthritis and systemic lupus erythematosus patients.”

In this study, researchers analyzed data on 681 rheumatoid arthritis and lupus patients without clinical cardiovascular disease, including two groups of rheumatoid arthritis patients (307 people) and a group of 374 lupus patients, that included electrocardiogram (EKG) results.

They also looked at QTc length and hydroxychloroquine use in these patients, adjusting for disease-specific characteristics and heart disease risk factors.

Of the whole study group (rheumatoid arthritis and lupus patients combined), 54 percent of patients used hydroxychloroquine. The QTc length among hydroxychloroquine users was comparable to that of those not using the drug. The researchers found that hydroxychloroquine did not significantly predict prolonged QTc for either the whole cohort or the rheumatoid arthritis and lupus patient cohorts.

What’s more, a prolonged QTc of more than 500 milliseconds was not associated with arrhythmias or deaths in these patients, and the study did not find any significant interactions between hydroxychloroquine and other QTc-prolonging medications.

In most cases, when hydroxychloroquine was paired with other QTc-prolonging medications, it resulted in a comparable QTc interval to when hydroxychloroquine was used alone. One exception was in the lupus group, where hydroxychloroquine paired with antipsychotic drugs resulted in longer QTc compared to hydroxychloroquine use alone.

“Overall, the use of hydroxychloroquine did not predict QTc length, even while adjusting for critical confounding factors, namely the use of other QTc-prolonging medications,” said Dr. Park. “Our findings reinforce the fact that hydroxychloroquine remains a safe, effective long-term disease-modifying drug for our rheumatic disease patients.”

Although the U.S. Food & Drug Administration (FDA) has cautioned against use of hydroxychloroquine or chloroquine for COVID-19 outside of a hospital setting or clinical trials due to risk of heart rhythm problems, it notes that this advisory does not affect FDA-approved uses for malaria, lupus, and rheumatoid arthritis.

Dr. Park notes that COVID-19 patients may have different factors affecting their risk than general lupus or rheumatoid arthritis patients.

“It’s important to remember that COVID-19 patients who received hydroxychloroquine were likely critically ill,” said Dr. Park. “Therefore, the effect of COVID-19 itself on the heart and subsequent arrhythmia must be considered. They also likely concurrently received azithromycin, another QTc-prolonging medication. Our next steps are to stratify data by length and cumulative dose of hydroxychloroquine therapy and analyze the associations with QTc length.”

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Glucocorticoids are a type of corticosteroid hormone that are used widely to lower inflammation in autoimmune and inflammatory diseases, including rheumatoid arthritis. However, these medications have a risk of many serious long-term side effects, such as high blood pressure, diabetes, and osteoporosis.

A new study presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology, found that Black patients with rheumatoid arthritis (RA) were more likely to use glucocorticoids and less likely to be prescribed a biologic treatment than white patients.

Biologics are more advanced and targeted therapies used to treat rheumatoid arthritis and other inflammatory diseases by acting on specific parts of the immune system, which lowers inflammation and prevents joint damage.

Researchers analyzed electronic health record data from 1,831 patients with rheumatoid arthritis at an academic center in Pennsylvania from 2010 to 2018. These patients had at least two rheumatoid arthritis diagnoses from an outpatient encounter, and at least one prescription of a disease-modifying antirheumatic drug (DMARD).

Of the patients in the study, 82 percent were female, 35 percent were Black, 54 percent were white, and the mean age was 55. Black patients in this study were more likely to be older, have a higher body mass index (BMI), be former or current smokers, and have higher rates of cardiovascular disease and diabetes.

The researchers found that there were racial disparities in how rheumatoid arthritis was treated between Black and white patients.

The glucocorticoid medication prednisone and conventional synthetic disease-modifying antirheumatic drug (DMARD) treatments (such as methotrexate) were used significantly more with Black patients than white patients: 79.3 percent of Black patients versus 69.1 percent of white patients used prednisone, while 96.7 percent of Black patients versus 93.5 percent of white patients used a conventional DMARD.

On the other hand, 74 percent of white patients versus 67 percent of Black patients were prescribed a biologic drug. Black patients had significantly more visits to the hospital emergency department over the span of eight years.

Previous research has also found that non-white rheumatoid arthritis patients have a lower frequency of biologic use than white patients, even when accounting for disease activity and treatment access.

“This project supports prior work showing reduced use of biologics and a greater use of prednisone in patients who were Black, which could potentially mean worse outcomes or increased steroid side effects in this group,” study coauthor, Michael George, MD, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania, said in a press release.

“A key next step that many are working on is understanding the key drivers of these disparities — understanding why they exist (e.g., access to medications, insurance, patient-provider communication, health beliefs, etc.) is important so we know how to address these disparities,” he said.

This study will add to existing literature covering racial disparities in rheumatoid arthritis care, which is key to improving the health of patients.

“With the explosion of effective therapies for rheumatoid arthritis, it is particularly important to make sure that we are treating patients in the best way possible,” said Dr. George. “Variability in practice, and disparities in treatment, suggest that there is room for significant improvement.”

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Methotrexate is a disease-modifying drug that is commonly used to tamp down inflammation in people who are newly diagnosed with rheumatoid arthritis or psoriatic arthritis. But could it also be an effective intervention for knee osteoarthritis, which is not a disease driven by systemic inflammation?

New research presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology, found that adults with primary knee osteoarthritis with some inflammation had significant improvements in levels of inflammation, as well as physical function of the knee, after three months of treatment with oral methotrexate.

Although the latest American College of Rheumatology treatment guidelines for osteoarthritis does not favor methotrexate, this seems to be largely based on evidence related to its use in hand osteoarthritis rather than knee osteoarthritis.

Many people with knee osteoarthritis have clinical signs of inflammation in the knee join, like swelling, warmth, and pain. This inflammation can lead to more pain, loss of function, and progressive damage in joints with osteoarthritis.

However, there are currently no approved drug therapies to address the progressive aspects of the condition. Pain relievers, steroid injections, and other treatments can address OA symptoms like pain, but do not change the course of disease.

This can eventually lead to the need for total knee replacement surgery.

Decreasing knee inflammation in these patients could help rescue the joint and perhaps prevent or delay the need for surgery.

Researchers at SSKM Hospital in Kolkata, India, compared oral methotrexate to a placebo treatment with glucosamine (a common supplement for pain relief in arthritis patients) in adults with primary knee osteoarthritis.

The male and female patients recruited for the study had primary knee osteoarthritis with swelling and pain in both knee joints for at least six months. They also had X-ray evidence of osteoarthritis. Researchers excluded those with advanced or secondary osteoarthritis, those who had undergone arthroscopy (a procedure for diagnosing and treating joint problems), those who had intra-articular steroid injection in the previous three months, and patients with renal or hepatic disease, uncontrolled diabetes, or gout.

The researchers checked patients with signs of local inflammation, like pain and swelling of the whole knee with warmth, for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood levels. Elevated levels are signs of increased inflammation. Patients who had increases in both inflammatory markers on one exam — or either marker on two exams — held one month apart were placed in an “inflammatory group.” Other patients were put in a “non-inflammatory group.”

Blood samples from all patients and healthy controls were tested for selected osteoarthritis biomarkers, and patients in the inflammatory group of primary knee osteoarthritis were screened for other inflammatory arthritis with blood tests, a clinical exam, musculoskeletal ultrasound and X-ray, and MRI scans of their knees.

Inflammatory group patients were randomly selected to take either 15 to 20 mg per week of oral methotrexate or 1,500 mg per day of glucosamine as a placebo, then were checked monthly for three months. The patients were allowed to take tramadol or acetaminophen for pain if necessary and were given non-steroidal anti-inflammatory drugs, or NSAIDs (a class of drugs that includes aspirin and ibuprofen) for seven to 10 days at the start of the study to improve compliance.

From July 2016 to June 2019, a total of 344 people with primary knee osteoarthritis were examined. The researchers found that 249 patients had local inflammation (or swelling with pain and warmth in both knees), and 172 of those 249 patients showed elevated erythrocyte sedimentation rate and/or C-reactive protein.

Patients with primary knee osteoarthritis with evidence of inflammation showed significant improvements on WOMAC scores (a commonly used measurement of physical function) and decreases in levels of erythrocyte sedimentation rate and C-reactive protein after three months of taking oral methotrexate.

Meanwhile, patients who took glucosamine showed no significant improvement in these measures of inflammation and function. The results of this study suggest that methotrexate can be an effective intervention for people with knee osteoarthritis who experience pain and inflammation.

“Treatments offered to patients with primary knee osteoarthritis are usually physical support and knee replacement, which are basically directed to manage the effect of the disease,” the study’s coauthor, Biswadip Ghosh, MD, an Associate Professor in the Department of Rheumatology at the Institute of Post Graduate Medical Education and Research in Kolkata, India, said in a press release.

“Our study provides hope to patients not only from this inexpensive molecule, methotrexate, but other therapies directed towards one cause of the disease: inflammation. We should think of using methotrexate if we find signs of both local and systemic inflammation in patients with primary knee osteoarthritis when conventional therapies are not helpful.”

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The bone-building osteoporosis drug romosozumab (Evenity) significantly improves bone mineral density in the hip and lumbar spine within one year, according to new research. What’s more, when patients transition to a potent antiresorptive drug after taking romosozumab, they experience even more bone density gains.

A loss of bone mass, measured by bone mineral density, and a change in bone structure leads to osteoporosis. Bone is constantly in a state of regeneration, as the body removes old bone (known as bone resorption) and replaces it with new bone (bone formation).

Previous research has shown that teriparatide, another type of bone-building medication, boosts bone mineral density in the spine and hip when followed by an antiresorptive drug.

However, when the antiresorptive drugs are administered first (particularly denosumab and bisphosphonates like alendronate), a patient’s hip bone mineral density may decline.

In a new study presented at ACR Convergence 2020, the annual meeting of the American College of Rheumatology, researchers reviewed results from four recent, large-scale trials to determine how romosozumab may be given in sequence with antiresorptive drugs. (These are osteoporosis medications that work differently from romosozumab.)

They found that osteoporosis patients showed significantly different results when they received romosozumab before an antiresorptive treatment compared to receiving it after.

Effects on the Hips

When patients were administered bone-building romosozumab before an antiresorptive treatment, their total hip bone mineral density increased by 6 percent in one study and 6.2 percent in another study over a year of treatment.

Similarly, the total hip bone mineral density gain was 7.1 percent when patients were administered romosozumab before alendronate (Fosamax) over two years of treatment. When they were administered romosozumab before denosumab (Prolia), total hip bone mineral density gain was 8.5 percent over two years.

However, when patients took the antiresorptive drug alendronate first, total hip bone mineral density increased by just 2.9 percent with romosozumab treatment. When they received the antiresorptive drug denosumab first, total hip bone mineral density increased by only 0.9 percent.

And over the course of two years, total hip bone mineral density gain was just 3.8 percent when patients were administered romosozumab after denosumab — less than half of when romosozumab was given first.

Effects on the Spine

The researchers found similar results on bone density in the lumbar spine. When patients were administered romosozumab before antiresorptive drugs, their spine bone mineral density increased by 13.7 percent in one study and 13.1 percent in the other study over the course of a year.

Similarly, over two years, receiving romosozumab before alendronate led to a bone mineral density gain of 15.2 percent. When patients received romosozumab before denosumab, the gain was 16.6 percent.

However, when patients took alendronate first, the lumbar spine bone mineral density gain was just 9.8 percent over the course of a year. When they received denosumab first, it was only 5.3 percent.

And over the course of two years, spine bone mineral density gain was just 11.5 percent when patients received denosumab before romosozumab.

What the Results Mean

These results may have important implications for patients, especially women who have had recent or multiple fractures in adulthood, since they are at high risk for more.

“These women need medication that can build bone mineral density fast to improve bone strength and reduce the risk of fractures,” the study’s coauthor, Felicia Cosman, MD, Professor of Medicine at Columbia University College of Physician and Surgeons in New York City, said in a statement. “The standard approach that most health care providers use is to start treatment with antiresorptive medicine. However, bone-building agents like romosozumab, abaloparatide, and teriparatide reduce fracture risk faster than antiresorptive medicines.”

The results of this study could help doctors and osteoporosis patients make more effective preventive treatment choices.

“There are about two million fractures every year from osteoporosis,” said Dr. Cosman. “Patients need to know that the best option for them might be to receive a bone-building medication first, rather than an antiresorptive treatment.”

Amgen Inc., which manufactures romosozumab (Evenity), is a corporate sponsor of the Global Healthy Living Foundation.

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