Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Eric Ruderman. He's an Associate Chief and Professor of Medicine in the Division of Rheumatology at Northwestern Medicine, and he's here today to talk about the highlights from the American College of Rheumatology Convergence 2023.

Dr. Ruderman, welcome back. You are very welcome to join these episodes with us, and I'm so glad you could join today to give us these highlights from ACR Convergence. Start by talking about what you feel were the most exciting research breakthroughs from the Convergence.

Dr Eric Ruderman: Sure. Thanks, Melanie. I really enjoy doing these. And I think that for us, as rheumatologists, this meeting every year, it's a highlight of the year where we get together and learn some of the newer things that are going to impact our practice now down the road.

I pulled a few presentations or abstracts that I thought were particularly notable in how they may affect clinical practice. And I thought I'd start with one that I actually think solidifies what we've been doing already, but it's important to see it done carefully. And this was one of the plenary session abstracts, one of the abstracts that pulled in everyone at the meeting. This was an Indian study looking at methotrexate in rheumatoid arthritis. And for those who aren't familiar with this, methotrexate has been our standard treatment for probably 40 plus years, given orally or sometimes as subcutaneous dosing. And a few years back, there was some data that suggested that oral dosing might not be as effective, because the absorption was maxed out before the full dose was really absorbed. And this was a study that looked at that. And as a result, many rheumatologists have begun splitting the dose of methotrexate each week. It was an open label, randomized trial in which patients took a single dose each week or split it over a 24-hour period. It was a study done in six centers in India and the very clear result was that split dose led to both better efficacy and less need for an additional medication to control the rheumatoid arthritis. And those additional medications in this particular study were either the leflunomide or sulfasalazine. And I think this is an important study for the practice because it really does confirm a practice strategy that many of us have been using for a few years, and that is to begin to split the dose of the methotrexate the patients are taking once they hit a certain dose of say 15 milligrams. But that has never really been carefully subjected to a clinical trial. And this was the first big trial to show that and confirm that assumption. And I think that's really helpful in informing clinical practice.

Another plenary session abstract that I thought was also very interesting was from a group looking at a VA database in the U.S. This was Dr. England, et al. And they were able to query the VA database, which is a very robust database of patient information in the Veteran Affairs Hospitals. They looked at patients who had rheumatoid arthritis with interstitial lung disease. And one of the questions for many, many years has been, "Are there certain drugs that are either more dangerous or more concerning in patients with interstitial lung disease, or perhaps might cause a progression of that disease? Or are there drugs that might potentially be safer?" And there's been some suggestion over the years that perhaps TNF inhibitors, one of our mainstays of therapy, may actually be worse in patients who have interstitial lung disease. They went ahead and queried this large database, they looked at about a thousand patients with interstitial lung disease associated with rheumatoid arthritis, and they looked at those who are on TNF inhibitors and those who are on alternate disease-modifying drugs, other biologics that were not TNF inhibitors, and they did the best they could to match those patients for the severity of their disease and the activity of their disease. And they found very clearly that there was no difference in the risk of hospitalization for pulmonary issues or death with the two different treatment arms. And I think this puts to rest, as best as we can, absent a controlled prospective study, I think it puts to rest the concern that TNF inhibitors may actually be detrimental for lung disease in patients with rheumatoid arthritis who have that disease. And I think that's very helpful information going forward as we manage our patients. Interstitial lung disease is a pretty common problem in rheumatoid arthritis. With as many as 20 or 30 or even 40% having some at least mildly symptomatic lung issues. And so, this is important information as we think about treating those patients.

Melanie Cole, MS: This is so interesting. And I'd like you to expand just a little more, Dr. Ruderman, as you're telling us how you're going to leverage some of these learnings into your practice. Some of the standout findings that you think, like the one you just mentioned, and how that's going to influence the approach to patient care, what that's going to change for you and what you want other providers to know about these changes, how that's going to influence their patient care.

Dr Eric Ruderman: Sure. And it's a great question. And I think that as much as we can, we do our very best these days to provide evidence-based care. And that is we make treatment choices in consultation with the patient because they obviously have an important role to play in making those choices and looking at the evidence that supports the different treatment options. There's never a single treatment for any given patients. There are always multiple options. And choosing between them can be challenging and we don't want to do it just because we guess or suspect that this might be better. We work off of some information that we had. But when we can, we like to look at data that supports a particular approach.

And then, I think is the key point of the two that I just talked about, the first in terms of methotrexate, we've been splitting the dose of methotrexate for some time, but without good data that says, "Yes, that's the right thing to do." And it's really helpful to have information that says, "Yes, that's the way to do it, and confirm that that's how we should be treating patients. And in the long run, they will have better outcomes if we do that. Same thing with the lung issues. In many cases, some physicians have shied away from TNF inhibitors in patients who have pulmonary disease with their rheumatoid arthritis, when in fact those drugs are very helpful in those patients. And it's nice to have data, clear cut data that says it's okay to use those medications. And so going forward, we can make those choices if those are the right treatments for those particular patients.

Melanie Cole, MS: That's what makes these annual meetings so vital for professions, Dr. Ruderman. I completely agree with you. Now, what about some notable highlights from presentations by your colleagues at Northwestern Medicine, those physicians?

Dr Eric Ruderman: Well, we have several physicians who presented at this meeting. And I must say this was not a year when we had physicians presenting really key research findings. We have a lot of physicians doing really advanced research in rheumatology and in many areas. But I think what was notable about this meeting for our physicians and our faculty is that people were asked to give talks in their area of expertise. And it really highlights the fact that we have a clinical faculty with expertise across a number of areas, not just in rheumatology, but in medicine.

So for example, Dr. Irene Blanco, who's our lupus expert, also happens to be very involved and very interested in issues of equity and diversity in medicine. And she gave several talks at this meeting. One speaking about disparities in medical care and the issues of equity in medical care. But also, another really interesting talk on diversifying our clinical workforce. And the key point of that is when you recognize that people come from different places and from different places in life to the clinic, it helps to have providers who understand those places. And until you diversify your workforce, you can't really provide the best equitable care to our patients. The last talk she gave was on trying to make these choices in medical education, to raise the next generation of providers to think about these issues as we're really trying to give our patients their best treatment, their best therapy, and be cognizant of the specific needs that they have relative to their backgrounds and what's important to them.

Melanie Cole, MS: Well, I'm glad you brought that up. And we do, listeners, have podcasts on those specific topics that Northwestern Medicine physicians have joined us to discuss diversity and disparity both within the medical community and without. So, thank you for bringing that up, Dr. Ruderman. And is there anything else before we wrap up? Any important information or learnings from this year's meeting that you'd like your colleagues who may not have been able to attend to know about?

Dr Eric Ruderman: Well, I think two things. One is that this is a nice meeting for everyone to get together each year and think about the way we approach care in our patients. And I highlighted some key areas. There were a number of other presentations. Some of the newer biologics that are coming out. We've had biosimilar agents, which are essentially generic versions of some of the biologic therapies. But some new data presented on biosimilars for new biologics were presented there, one on tocilizumab. There was data on new ways of administering biologics. Some of the drugs we use have to be given subcutaneously. But for patients on Medicare, that's sometimes not cost effective or not even something they can manage. And so, intravenous ends up being a better way to go. And there was data on intravenous versions of secukinumab, an interleukin-17 antagonist. Just a lot of data on ways in which we can leverage the information we have to better treat our patients and to give them the treatment that's really appropriate for them.

And hopefully, in the long run, think about costs. And I think that was a big theme through this, is think about the cost of delivering care. We're beyond the point at which we can just continue to do what we want to do and not worry about paying the bill down the road. And so, I think thinking about that sort of carefully and prospectively, and thinking about how cost rolls into treatment choices, still maintaining the best treatment choice for that patient, but being cognizant of the cost of those treatments was a really big piece of this meeting.

There was another paper that I thought was really interesting, presenting some early recommendations on who to refer to rheumatology. So, we see a lot of patients with rheumatoid arthritis. We also see patients with spondyloarthritis. And the challenge is we want to make sure they get to us in rheumatology from their primary care physician. But we don't want to be inundated with people who may not have the diagnosis. And so, they looked at some recommendations. And I thought what's really interesting is they started with a consensus that said if only a third of the people they refer end up having the diagnosis for which they're being referred, that's reasonable and that's an appropriate use of those resources. And so, those are the kinds of questions that people are thinking about in this area and the kinds of things that are discussed at these meetings that, overall, really help us deliver better care over the long run.

Melanie Cole, MS: That's really the whole point too, Dr. Ruderman. And I thank you so much for joining us. Sounds like a fascinating meeting, and thank you so much for summarizing some of the highlights that you felt were really, really important. So, thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rheumatology to get connected with one of our providers. That concludes this episode of BetterEdge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for tuning in today.