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Rheumatology trends, research, concerns highlighted for 2016


 

References

Dr. Volkmann expressed interest in seeing how the ACR’s Choose Rheumatology! mentorship program is performing. The program seeks to pair students and residents with rheumatologist mentors who will offer advice and help to guide them. She also pointed to the European League Against Rheumatism’s working group for young rheumatologists, the Emerging EULAR Network (EMEUNET), which seeks to promote the educational, research, and mentoring needs of young clinicians and researchers in rheumatology in Europe. as a potential model for the ACR to use in the United States.

Some of the conference-based resources available to rheumatology fellows include the ACR’s 2016 State-of-the-Art Clinical Symposium, which provides a presymposium course specifically for fellows and has sessions on choosing career paths, and the Rheumatology Research Workshop, which targets rheumatologists interested in pursuing an academic research career. Fellows-in-training travel scholarships are available for both conferences.

Dr. Virginia Steen

Dr. Virginia Steen

New systemic sclerosis and microbiome research

Many new studies in systemic sclerosis will build on results obtained in earlier-phase trials or unanswered questions arising out of treatment comparison studies. “It is a very exciting time in the world of scleroderma,” said Dr. Virginia Steen, professor of medicine at Georgetown University, Washington.

At least four new trials are studying treatments for skin manifestations of systemic sclerosis, noted Dr. Steen. In patients with diffuse cutaneous systemic sclerosis, the phase II ASSET study is testing abatacept (Orencia) against placebo and another phase II study is testing riociguat (Adempas). Roche has started enrolling patients for a phase III trial of tocilizumab (Actemra) on the heels of positive findings from its phase II study. Dr. Steen and colleagues at Johns Hopkins University are also finishing up a pilot study of the effects of intravenous immunoglobulin (Privigen) on skin disease in systemic sclerosis and should have results ready for 2016.

Two additional trials will be investigating treatments for interstitial lung disease associated with systemic sclerosis: the Scleroderma Lung Study III, testing the use of mycophenolate mofetil in all patients with the addition of pirfenidone (Esbriet) or placebo, and a separate phase III study of nintedanib (Ofev) vs. placebo that just began enrolling patients.

There are also several trials of add-on therapies, including topical nitroglycerin for Raynaud’s phenomenon or riociguat for digital ulcers, and another that is testing autologous adipose–derived regenerative cells for the treatment of hand dysfunction.

Dr. Daniel E. Furst

Dr. Daniel E. Furst

In addition to these trials now underway, the expected 2016 publication of the validation of the Combined Response Index for Systemic Sclerosis will hopefully “lead to real movement forward in the treatment of systemic sclerosis,” said Dr. Daniel E. Furst, the Carl Pearson Professor of Medicine at University of California, Los Angeles.

Further examination of the Wnt signaling pathway in systemic sclerosis should also bring better insights into the disease’s pathogenesis and potential for treatment, Dr. Furst noted, as recent experimental results have shown that its activation induces fibroblast activation with subsequent myofibroblast differentiation and excessive collagen release. Small-molecule inhibitors of Wnt signaling in early clinical trials have shown promising results.

Dr. Furst and Dr. Volkmann said they also hope for studies describing better and more specific data regarding the microbiome in rheumatic disease, especially systemic sclerosis and rheumatoid arthritis, both of which have microbiome data linked with clinically meaningful outcomes (Nat Med. 2015 Aug;21[8]:895-905).

An important unanswered question, Dr. Volkmann said, is whether differences found in GI microbial composition between diseases and between different disease subtypes are clinically meaningful.

Dr. Roy D. Altman

Dr. Roy D. Altman

OA treatments: AAOS guidelines, OTC topical NSAIDs

The repercussions of the American Academy of Orthopaedic Surgeons 2013 clinical practice guideline’s statement on intra-articular hyaluronic acid treatment of knee OA will continue to be felt in 2016, according to Dr. Roy D. Altman, professor emeritus of medicine at University of California, Los Angeles.

The AAOS took a different stance from all other recent treatment guidelines for knee OA by stating: “Intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee.” The AAOS’s recommendation didn’t create much confusion with physicians and patients because its use continues to increase, but instead it has contributed to “a plethora of contradictory publications and increasing resistance on coverage by insurance carriers,” Dr. Altman said.

Another unresolved issue in OA treatment is “the resistance of the FDA to approve over-the-counter topical NSAIDs,” Dr. Altman said. The FDA requires a new drug application for OTC topical NSAIDs demonstrating efficacy and safety, “as if they were completely new,” when the safety exceeds presently approved OTC oral NSAIDs and has already been shown for prescription topical NSAIDs, he said.

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