Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast physicians. I'm Melanie Cole. And today, we're highlighting sleep disturbance in rheumatoid arthritis patients and highlights from the ACR 2024. Joining me is Dr. Yvonne Lee. She's the Helen Myers McLoraine Professor of Rheumatology and an Associate Professor of Medicine in Rheumatology at Northwestern Medicine.

Dr. Lee, thank you so much for joining us today. I'd like to jump right into ACR 2024. Can you give us a bit of an overview of some of the highlights of the convergence overall? What sessions or presentations left a lasting impression on you? Tell us about any breakthroughs or research that you want to talk about today.

Dr. Yvonne Lee: Yes. Thank you, Melanie. It's great to be here. So, one of the things that really impressed upon me was one of the plenary sessions by Dr. Peter Merkel from the University of Pennsylvania when he reported on the results of a randomized control trial for giant cell arteritis. So, this was a phase 3 trial of a JAK inhibitor, upadacitinib. And in this study, they randomized 420 participants to receive either upadacitinib in combination with a 26-week steroid regimen or placebo with a longer steroid regimen of 52 weeks. And they found that a greater percentage of the patients randomized to upadacitinib 15 milligrams daily achieved sustained remission at 52 weeks, compared to those in the placebo group. And that group also had lower cumulative steroid exposure and greater improvements in fatigue. So, this was really promising, I think, in having some data that supports the role of JAK inhibitors for treating giant cell arteritis in the future.

The second study was also presented by Dr. Merkel, and this study looked at use of low-dose steroids to maintain remission in patients with granulomatosis with polyangiitis or GPA. . And so, basically, participants were tapered to prednisone 5 mg daily. And after that, they were randomized to either stay on prednisone 5 mg daily for six months or to taper off prednisone to 0 mg per day in four weeks and to stay off. And so, in this study, 4% of participants randomized to prednisone 5 mg daily for that six months had a relapse compared to 15% of participants randomized to taper off.

Interestingly, they also conducted a stratified analysis, stratified by the use of rituximab. And among those getting rituximab, there was actually no difference in relapse rates regardless of the steroid regimen. Basically, for those not taking rituximab, 20% in the taper group relapsed compared to 3% in the group receiving prednisone 5 mg daily for six months. However, most relapses were minor, and there were no differences between arms in patient-reported outcomes of fatigue, pain interference, and physical function.

So, the take-home message seems to be that if your patient is on rituximab, it may be reasonable to taper them off prednisone relatively quickly. If they are not, then you probably still need to weigh the risks and benefits of what you or the patient thinks of a 20% relapse rate. Though again, the majority of these relapses were minor, so that is very comforting.

Melanie Cole, MS: Sounds like an interesting convention. Now, were there specific learnings, Dr. Lee, that you plan to integrate into your practice right now.

Dr. Yvonne Lee: I think what I mentioned earlier about kind of the steroids and how to manage steroids in patients with granulomatosis with polyangiitis was interesting, so I think that I may think about implementing. Also, there were some things I learned actually from patient advocates who were attending the meeting. For example, patient advocates, Cheryl Crow and Eileen Davidson had collated a list of patient resources for patients with rheumatoid arthritis, specifically geared towards common symptoms that are not joint pain, so things like fatigue or cognitive dysfunction and sleep problems. And so, I found that to be actually really helpful and I'll be referring my patients to this list of resources, which are on Eileen Davidson's website. And then, also, I learned that occupational therapists are frequently trained in cognitive behavioral therapy for insomnia. And so, I'm going to talk about this probably a little bit later. But if it's difficult to get cognitive behavioral therapy for insomnia, that referring patients to occupational therapy may be an alternative way to go.

Melanie Cole, MS: That is so interesting. Now, you had a presentation. Tell us the key takeaways and notable highlights from your own presentation.

Dr. Yvonne Lee: My presentation was mainly about managing sleep and sleep disturbances in patients with rheumatic diseases, and I think the main takeaways there are that sleep problems are frequently multifactorial in origin, that is there are lots of factors that play into how we sleep. And as a result, the management of sleep likely requires a potentially more than one thing, but a combination of strategies. And that also each person is unique and has their own set of contributors to sleep problems. The sleep problems need to be individualized to the patient. And then, when thinking about these different components, you know, one needs to think about obviously controlling their inflammatory disease activity and minimizing medications that disrupt sleep, like steroids. But fundamentally, after that, the foundation for most sleep management strategies is non-pharmacologic, and so really stressing non-pharmacologic strategies.

Melanie Cole, MS: Now, why don't we talk about that, the prevalence of sleep related disorders in patients with rheumatic disease? Why is it so important for these patients to identify these sleep disorders and manage them and how does it impact the disease activity?

Dr. Yvonne Lee: Sleep disturbances are very common in patients with rheumatic diseases. About 55-80% of patients with rheumatic diseases report sleep disturbances or poor sleep quality. These patients may not all be specifically diagnosed with a sleep-related disorder however. Dr. Patty Katz, one of my co-presenters in the session, published a paper in Arthritis Care and Research in 2023, which reported on the prevalence of sleep disorders in patients with rheumatoid arthritis specifically. And in that study, almost two-thirds of patients met criteria for at least one sleep disorder, 43% reported short sleep, 30% had symptoms or a diagnosis of restless leg syndrome, and 21% were either diagnosed with obstructive sleep apnea or were deemed to be at high risk for obstructive sleep apnea.

So in answer to your first question, the prevalence of sleep-related disorders is high. And then, to your second question, which is why is sleep so important for these patients and how does it impact disease activity? There's been a little bit of literature, so not a lot, but some data that suggests that if you're not sleeping well, at least acutely, that this affects your disease activity thereafter.

So in particular, there was one study where patients with rheumatoid arthritis were enrolled in a study and they went to a sleep lab where they underwent partial night sleep deprivation. And then, they followed them the next day and they found that the patients reported more pain and more arthritis symptoms the day after a partial night sleep deprivation as compared to a night where they slept normally and fully.

Melanie Cole, MS: That would make sense. And we're learning more and more about sleep disorders and how they are affecting obesity and diabetes and heart disease. And so many things are related to our sleep. So, it wouldn't surprise me that immune disorders also have increased activity when there's sleep disorders. So, what strategies do you recommend for managing some of these disturbances and for other physicians whose patients might be struggling with sleep? What do you recommend?

Dr. Yvonne Lee: As I alluded to earlier, I think non-pharmacologic strategies are the bedrock of sleep management. And so, the first thing would be education about sleep hygiene. And there are a lot of great resources from the CDC, Arthritis Foundation, and Lupus Foundation, which go into details of this. And so, you can go onto their websites and print out resources for your patients. But basically, it includes concepts such as going to bed and getting up at the same time every day, keeping the bedroom quiet, relaxing, and maybe keeping your temperature in your bedroom at a cool level, so between 60 to 70 degrees Fahrenheit, things like that.

The second would be a referral for cognitive behavioral therapy, or CBT, for insomnia. Now, depending on where you're located, this could be through a sleep medicine center, or as I noted earlier, what I recently learned was that occupational therapists are often trained in this, so you may want to consider referral to occupational therapy if you don't have access to other resources like a comprehensive sleep medicine center.

 Lastly, I would really recommend encouraging patients to exercise or if they're not able to exercise, or if the concept of "exercise" makes them nervous or anxious, to at least increase their physical activity. There have been multiple studies suggesting that physical activity can improve patient-reported sleep quality. So, I would really focus on those non-pharmacologic therapies and educating patients in them.

Melanie Cole, MS: That's good advice. Now, as we get ready to wrap up, important takeaways, exciting developments from the meeting that you'd like to share with other healthcare providers who are unable to attend and a summary of the advice that you give physicians looking to integrate some of this latest research and treatment approaches that you've been discussing here today into their own practices.

Dr. Yvonne Lee: So, one of the important takeaways was really the importance of the voice of the patient. ACR has done a really great job in recent years of incorporating and elevating patient perspectives at the meeting. And for my session in particular, it was really great to have patients in the audience who can contribute their experiences and how they each individually have successfully navigated managing various aspects of their disease. So, I thought that was really cool.

And then, as to advice for physicians looking to integrate latest research, obviously, it's tough. Medicine is evolving rapidly. So, I think committing to continuous education is very important. This can be done through attending conferences like ACR Convergence annually, or if you're not able to get there, by accessing some of the sessions online. You know, on a more practical day to day basis, what I do is just try to keep up by reading medical journals or I do a lot of UpToDate. And then, in terms of which journals or which articles to prioritize, I try to prioritize clinical guideline papers. I search periodically to see if any new ones have come out. The American College of Rheumatology or ACR website has a nice part of their website where they collate some of these guidelines. So, that's a great resource.

And lastly, I'm not the best at remembering things if all I'm doing is reading about it or hearing about it in a presentation, so it's always good for me to cement things in my brain by having discussions with my colleagues, either informally or through journal clubs. So, I think that would be my advice there.

Melanie Cole, MS: Thank you so much, Dr. Lee, for joining us today. 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. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.