ORADE Grant Recipient – Anne Macleod

Anne Macleod is an AHPA member and recipient of a 2017 ORADE Grant. In this article she shares her learnings from the 2017 ACR Conference.

I would like to thank the ORA for their financial support for my attendance at the American College of Rheumatology 2017 Annual Meeting in San Diego, CA.

I took the opportunity to attend the ACR Review Course on the day prior to the conference.  Three pearls included:

  • Patients with secondary Raynaud’s Phenomenon have structural disease in the microcirculation involving the nutritional arterioles and capillaries which can lead to critical ischemia (not present in primary Raynaud’s). Macrovascular disease also occurs, and occult disease can lead to crisis thus must consider clinical tests such as Allen’s test for the upper extremities and Bueger’s test for the lower extremities to evaluate macrovascular disease. If confronted with lower extremity digital ischemia, an ankle brachial pressure index is a mandatory part of the clinical exam. ABPI < 0.9 demonstrates 95% sensitivity for the presence of angiographic proven disease. Flavahan NA. A vascular mechanistic approach to understanding Raynaud phenomenon. Nat Rev Rheumatology. 2015 Mar;11(3):146-58
  • Axial Spondyloarthritis: Sentinel data – the majority of HLA B27 anterior uveitis patients with no prior arthritis diagnosis, have Spondyloarthritis (axial > peripheral: 69.8% to 21.9%). Juanola X et al. The Sentinel Working Group August 2016. Ophthalmology Vol 123 (8), 1632-1636.
  • Ankylosing Spondylitis: A family history of Ankylosing Spondylitis or anterior uveitis is useful for diagnosing axSpA(HLA B27+ve) however ReA, IBD, or psoriasis does not contribute to identifying axSpA in Chronic Back Pain patients. Ez-Zaitouniet al. Arthritis Research & Therapy (2017) 19:118
  • A recurrent theme both within the review course, posters and talks related to imaging in Ankylosing Spondylitis- In early disease, structural damage assessed in pelvic radiography has low sensitivity to change. MRI-SIJ is a promising alternative capturing more structural changes.  In contrast, there is no indication that MRI-spine is better than x-spine in detecting structural changes. Ez-Zaitouniet al. Arthritis Research & Therapy (2017) 19:118.  Sepriano et al. Poster 592. Which Imaging outcomes for axSpA are most sensitive to change?  A 5-year analysis of the DESIR cohort.
  • Cardiovascular Disease and Rheumatoid Arthritis.

Data from the CORONA Registry 2015 showed that lower disease activity predicts lower CV event rate – a 10-point decrease in CDAI equals 26% decrease in cardiovascular risk and that patients in remission had a 53% lower CVD risk.

A recent PET scan study showed that RA patients had vascular inflammation similar to patients with CVD and that inflammation resolved with biologics used to treat arthritis.  RA features that increased risk for CVD were nodules, higher ACPA levels, greater disease activity, Hypertension and elevated BMI.

Treatments for RA associated with lipid changes are not specific to the treatment but more to disease activity (inflammation).  The greater the decrease in CRP the greater the increase in LDL levels. We know that elevated LDL is associated with increased CVD but LDL measurement is a balance of synthesis.  In good disease control, LDL levels may increase due to the flux of disease state thus lipids should be measured when disease is stable or in remission.

Treatments that modify CVD risk include Methotrexate, Biologics (no difference between different biologics) and possible Hydroxychloroquine (as decreases risk for diabetes).

Statins (such as atorvastatin) are safe and effective at decreasing LDL in RA thus have a place in treatment but not clear if they have a place in prevention.

  • Update on Juvenile Spondyloarthritis:

A discussion of pathogenesis – 90% heritable but only ~20% accountable with HLA B27 gene thus large percentage unknown genetics.  Functional genetics indicates that HLA B27 can trigger release of IL17/23 thus possible important target for treatment in children as in adults.  IL23 may induce SpA by acting on entheseal resident Tcells (recent mouse study).  HLA B27 may also alter gut microbiota in SpA as early studies have observed that the # of fecal microbiota relates to disease activity.

Peripheral disease is predominant first in children and then axial.  Risk factors for SI joint involvement include elevated CRP, positive HLA B27, increased joint count or enthesitis count and hip pain (dactylitis protective).

Enthesitis is most common at the lateral epicondyle, suprapatellar and achilles sites on ultrasound but this does not always correlate clinically on physical exam.

Bowel inflammation is sub clinically predominant.

Future treatment options include the IL17/23 or IL 23 medications along with the JAKs.

  • Osteoarthritis Beyond the Guidelines:

OA includes a state of chronic low-grade inflammation in the synovium, cartilage and bone. Altered biomechanics promote inflammation with the OA joint tissues and creates a feed forward cycle that promotes damage in OA.  Inflammation is largely macrophage stimulation and not lymphocyte stimulation as in Rheumatoid Arthritis thus OA is an innate immune driven process rathe than an adaptive immune process. The IL1Ra gene is associated with early onset OA and joint space narrowing is consistently associated with the presence of this gene.

Serum biomarkers – Increased levels of IL1 predicts rapid progression as well as increased pain scores (burden of disease).  PGE2 (made in the joint) can be measured in the serum thus may be able to be used as a diagnostic tool.  Serum level of Uric Acid predict joint space narrowing in non-gout patients with medial knee joint OA (as UA increases there is increased synovium and increased joint space loss perhaps elated to inflammatory process in OA joint).

Increased BMI is related to hand OA as part of a Metabolic Syndrome thus may be able to alter disease process in future with metabolic manipulation.

  • New PsA Guideline – quitting smoking is the strongest recommendation.
  • Exercise is Medicine – fist question to patients should be about activity and exercise NOT medications. Need to place an emphasis on exercise rather than an afterthought – need to ask about and prescribe.

Thank you to the ORA for the opportunity to attend ACR, to network with colleagues from around the world and to visit beautiful San Diego.