Thread by @psufka

#ACR19 Review Course — Update in RA Therapy 2019 — Dr. Michael Weinblatt.

My notes in thread ⬇️⬇️⬇️

SQ MTX offers the advantage of delivering 100% of the med to the patient.

Split dose oral MTX also increase bioavailability >28% over single dose.

Also important to make sure you escalate the dose of MTX up to 20-25mg/wk.
#ACR19

2/3 of patients don’t achieve low disease activity or remission on MTX alone. These pts need another agent.

Keeping them on MTX increases the efficacy of some biologics (TNFi, RTX) and helps prevent drug-blocking antibodies.

#ACR19

If patients are in low disease activity or remission, the lowest dose of MTX you can go to should be 10mg/week.
#ACR19

MTX and flu vaccine: holding 2 doses of MTX *after* flu vaccine may improve development of vaccine response. (Although no different in disease). Hard to know if we should be doing this yet.
#ACR19

MTX in CV prevention — NEJM trial in 2019 did *not* show improvement in major CVD outcomes. (These pts did not have RA/inflammatory dz).

Similar study: CANTOS (NEJM) showed improvement in CVD with IL-1 blockade.
#ACR19

MTX toxicity: most common side effects can be prevented with folic acid.

Can also use folinic acid (leucovorin) 5mg/wk day after MTX helps with residual sx.

(I also see great improvement in GI sx, oral ulcers with vitamin A)
#ACR19

Paternal MTX use — ACR 2018 abstract 1853: did not show risk of fetal abnormalities #ACR19 #ACR18

Anti-TNF withdrawal studies:

80% of pts who stop TNF will flare, but some patients can reduce dose/frequency of TNF (about 40%). These pts should stay on background MTX. #ACR19

Lymphoma and anti-TNF risk. Need to know that it’s the RA disease activity that causes the lymphoma — NOT THE DRUG.

No major increase in cancer recurrence with TNFi as well.
#ACR19

People also worry about infections with TNFi — but the real risk is seen from glucocorticoids. If you can do nothing else for your pts, get their steroid dose down <10mg/d (especially before joint arthroplasty).

Also no major increase of infection with long term RTX.
#ACR19

Dual cytokine inhibition in RA — Arthritis Rheum 2018;70:1710 looked at TNFi + IL-17 blockade. No greater efficacy, but 4x risk of infection. #ACR19

Now 3 different JAKi available. These work quickly (you should know within 4-8 weeks). Side effects include infection, zoster, anemia (related to mechanism of action).
#ACR19

More about JAKi side effects:
- Zoster — clearly higher risk. Hopefully the new shingles vaccine will show decrease in this risk.
- No increase in cancer risk has been noted.
- DVT/PE — seems to be a dose dependent risk, esp in pts >65yo, elevated BMI, history of clot #ACR19

Infection risk with JAKi — pts with lower disease activity had lower risk of infection. #ACR19