John Cush, MD: Rheumatoid Arthritis Year in Review

Rheumatology Network sat down with John Cush, MD, to discuss his upcoming lecture entitled, “Rheumatoid Arthritis: Year in Review,” which will be presented at the Congress of Clinical Rheumatology. Cush is the Executive editor of RheumNow.com. He explains the key takeaway points of his presentation, the role of COVID-19 in the changing treatment landscape, and what is in store for rheumatology in 2022.

Read a preview of the interview below:

Rheumatology Network: What are the key takeaway points of your presentations?

John Cush, MD: Well, in this “Year in Review,” I'm going to cover things that are interesting to me, which I think are interesting to rheumatologists because I think we have this a lot of the same concerns. And some of the data that's come out in the last few years, especially in the last year, that I think are either telling us we're doing great, or that we could do better. So, you know, we love steroids, but we know steroids are the most wonderful drug we have and the most dangerous drug we have. And there's good data that's accumulating now that even low doses of steroids really do have damaging effects. And that, you know, 5 milligrams and less [can mean a] higher risk of serious infection, higher risk of cardiovascular events. And even though we have lots of great biologics and targeted synthetic disease-modifying antirheumatic drugs (DMARDs), new advanced therapies that are entered our arsenal to treat rheumatoid arthritis (RA), we're not doing really good at getting our patients off steroids. So, there's great information about that, great information about the janus kinase (JAK) inhibitors and where they are really jumping out in our arsenal and why that they're challenging methotrexate for king of the hill. But JAK inhibitors are currently being held that held back by a number of safety concerns, which are under review in the FDA. There's even more information about safety issues that rheumatologists are interested in. A great study on drug safety comes from gastroenterology literature, the PIANO study, that looked over 1000 patients with Crohn's disease, and what their drug use was like. Crohn's disease is different than RA in that often patients need to be on their biologic, their DMARD. They studied patients on no therapy, on thiopurines, and on biologics, largely tumor necrosis factor (TNF) inhibitors. And they showed that the use of advanced therapies during pregnancy are not associated with major effects on either the mother or the baby, certainly no increased risk of malformation. So, again, there's an evolution of data that tells us some of the things we're doing are great, some of the things we still need to work out.

RN: What do you believe is in store for rheumatology and rheumatoid arthritis in 2022?

JC: I think greater debate about the use of JAK inhibitors. Will they take a more prominent role? And that's partly because the data is good, the data is safe. But then, because of the problems with the ORAL surveillance study and Pfizer's tofacitinib, a lot of new drug approvals a new a lot of indications for JAK inhibitors are being put on hold pending that particular analysis. So, in the next year, we're going to see JAK inhibitors approved for psoriatic arthritis, atopic dermatitis, for ankylosing spondylitis. I published today on my website that filgotinib, a JAK-1 inhibitor, shows protection against sacroiliac (SI) erosionsin as little as 12 weeks. We never could get good data on X-ray changes in ankylosing spondylitis/spondyloarthritis because it's a slower disease and takes a longer time. It's harder to get that proof. Now a 12-week study of less than 100 patients has made the case. So, what I'm saying is that bringing JAK to the forefront in the discussion getting more indications, which will drive this discussion, is going to make it a very interesting consideration. And what happens there is it's going to challenge traditional use of therapies. So, should we be using triple DMARD therapy as James O’dell and others in the Rheumatoid Arthritis Investigational Network (RAIN) have said? That thing is very strong, it's undeniable. But this is easier therapy. And the problem with some of the triple DMARD therapy is that the data for longevity on triple DMARD is just not as good as methotrexate alone or as a JAK inhibitor alone. It's going to question the use of TNF inhibitors, this first line that's going to continue to fall under increasing scrutiny and more debate. So, the idea used to be that everybody got methotrexate, I still think that's going to be true, but your next drug may not be a TNF inhibitor, which is often mandated by insurance carriers. But again, I think the data is going to drive the discussion. So, I see that this particular area is going to be a hot discussion. I think that we'll get more into the subset treatment of RA, different types of RA. So maybe focusing more on seronegative RA, focusing more on preclinical RA, focusing more on the surgical RA patient because while that's gone down with more aggressive therapies, there still is a significant population there that may be surgical candidates and most of the surgical studies that that we've covered in the last few years, really don't pan out to be all that useful. When you look at longer-term outcomes beyond the short-term relief of pain and when you look at longer-term pain function, a lot of orthopedic procedures in rheumatology, ust don't pan out as being worth the trouble and costs and risk. RN: Is there anything else that you'd like to add before we wrap up?

JC: I think the biggest challenge to rheumatologists is how do I continue to be smart? Because all those usual ways of getting together with your colleagues and peers and rubbing elbows, sharing opinions, giving insights, learning what to do in difficult situations, which happened very easily, such as live face-to-face meetings in your city, in your university, at a national meeting on a review course, isn't happening. And as best I know, most people are really perturbed at Zoom, and my doing this video to talk to them. And i'm not; i'm excited. I think they should embrace the opportunity to learn in new ways. As long as they are structured in ways that meet your needs, you have to dive into it. Because if you're waiting for the past to come back, you are part of the past and you are not part of the future because this is the future. So, I think that's the biggest challenge for all of us rheumatologists, me included.