EULAR 2020: 50+ Updates That Could Change the Way You Treat Your Arthritis

This article has been adapted, with permission, from a corresponding article by Lauren Gelman published on the CreakyJoints (US) website on 23 June 2020. Some content relating to drugs and prescribing practices may not be relevant in Australia. It is important to discuss the drugs and doses relevant to you with your treating doctor.

Please note that some of the links will redirect you from the CreakyJoints Australia site (creakyjoints.org.au) to the CreakyJoints (US) site and other international sites.

 

In normal circumstances, international medical conferences like that of EULAR, the European League Against Rheumatism, consist of long days packed with in-person sessions and hours roaming poster and exhibition halls filled with updates in rheumatology research. The goal: to provide rheumatologists and other health care providers with the latest scientific advances and clinical guidance for treating rheumatic and musculoskeletal diseases.

Because of the COVID-19 pandemic, the 2020 EULAR meeting was quickly switched to a virtual one, renamed the EULAR 2020 E-Congress. Participants could attend live and recorded virtual sessions and read about research updates (abstracts and posters) online. Of course, attending a medical meeting online has its shares of pros and cons compared with attending in person, but the important thing is that — whether virtual or not — research news is shared with the global rheumatology patient community.

Research from major medical conferences can directly affect how you and your providers treat and manage your conditions. We hope these updates help you to ask your provider questions, improve your understanding of your rheumatic conditions and ultimately improve your care, so you can live with less pain, fatigue and disruption to your daily life.

Our CreakyJoints (US) team read through hundreds of studies, curated conference coverage from health care provider-focused websites and asked our medical advisors for their thoughts on the most impactful research for patients. Below is a sample of what we think you should know from the EULAR 2020 E-Congress.

Here is a table of contents to the sections in this resource:

• COVID-19
• Rheumatoid Arthritis
• Methotrexate
• Psoriatic Arthritis
• Axial Spondyloarthritis
• Gout
• Lupus
• Osteoarthritis
• Fibromyalgia
• Mental Health, Wellness, and More

And FYI: You can participate in research studies about arthritis by using our ArthritisPower app to join our patient-centred research registry.

COVID-19

The biggest study yet of rheumatic disease patients with COVID-19 reveals some surprising things about which patients are (and are not) at risk. A study published in the run-up to EULAR — and which was widely discussed during the conference — analysed 600 case reports in the COVID-19 Global Rheumatology Alliance that were sent to this registry between 24 March and 20 April 2020 by physicians from 40 countries. Among other things, researchers found that age had a big impact on hospitalisation, certain rheumatic conditions were more likely to require hospitalisations than others, comorbidities increased the likelihood of hospitalisation and while glucocorticoids were linked with hospitalisation, other medications were not. Read more here about the findings.

Rheumatoid Arthritis (RA)

Remission rates were high when RA was treated very early — regardless of treatment regimens. In a randomised trial of patients with very early RA across Sweden, Norway, Finland, the Netherlands, Denmark and Iceland, researchers are seeking to understand the efficacy of different treatments in very early stages of the disease. They randomised patients to four different treatment groups and followed them for six months: conventional therapy (methotrexate plus tapered prednisone or methotrexate plus sulfasalazine, hydroxychloroquine and intra-articular glucocorticoid injections in swollen joints) or one of three different biologic medications: abatacept (Orencia); certolizumab pegol (Cimzia) or tocilizumab (Actemra). After the first month, patients in all the groups received methotrexate weekly as well.

The researchers found that high remission rates (roughly 40 to 50 per cent) were observed for all treatment regimens, with abatacept performing the best: 52 per cent of patients on it were in remission within six months.

“These data suggest that conventional therapy has comparable efficacy to certain biologics in the treatment of early RA,” reported Rheumatology Advisor. “High remission rates were observed across all study arms, though abatacept combined with methotrexate was associated with greatest symptom improvement.”

When it comes seeing a rheumatologist for RA symptoms, the earlier the better. A team of Dutch and French researchers looked at two databases of rheumatoid arthritis patients to see if seeing a rheumatologist sooner after the onset of symptoms led to better outcomes over time. “They found that patients who saw a rheumatologist within six weeks were more likely to ultimately be in remission without strong RA medication than those seen in seven to 12 weeks or more than 12 weeks,” says Theodore R Fields, MD, a rheumatologist at Hospital for Special Surgery in New York City. “This argues for earlier referral of patients with RA to a rheumatologist.”

Should RA patients in remission on a biologic start tapering the dose? Probably not, according to a study that randomised 84 RA patients who were in remission for a year on stable TNF inhibitor biologics to either continue taking their medication or taper it over the course of four months.

“The group that withdrew the TNF inhibitors had a 63 per cent flare rate and those who stayed on the TNF inhibitors had only a 5 per cent flare rate,” says Dr Fields. Fortunately, patients who flared did well when the TNF inhibitor was restarted. “This study raises questions about whether to taper a TNF inhibitor in view of the high flare rate. However, since patients did well with a restart of the TNF inhibitor, tapering and withdrawal is still an option for some patients.”

Adds Vinicius Domingues, MD, a rheumatologist in Daytona Beach, Florida, “these results show that caution is needed prior to tapering or stopping TNF inhibitor biologics in patients in RA regardless of remission state.”

A forthcoming JAK inhibitor, filgotinib, did well in a series of studies. Part of a growing class of JAK inhibitors — oral pills that that target specific immune system pathways to treat inflammatory conditions — filgotinib is seeking FDA approval this year (for use within the US). In one study, patients were randomised to one of four groups: 200 mg of filgotinib plus methotrexate; 100 mg of filgotinib plus methotrexate; a placebo and methotrexate or the biologic adalimumab (Humira) and methotrexate.

According to MedPage Today, “more patients who received one of two doses of filgotinib (100 mg and 200 mg) achieved American College of Rheumatology Criteria of at least a 20 per cent improvement in the number of tender and swollen joints at week 12 versus placebo” and “a greater proportion of patients treated with 200-mg filgotinib achieved low disease activity … compared with adalimumab-treated patients at week 52.”

In a separate but related trial of RA patients who had never taken methotrexate or a biologic, patients were randomised to groups that included 200 mg of filgotinib plus methotrexate; 100 mg of filgotinib plus methotrexate, 200 mg of filgotinib alone or methotrexate alone. According to RheumNow.com, after one year, patients on MTX alone did worse than the other three groups.

When an RA patient doesn’t do well on their first biologic medication (or even multiple biologic medications), what treatment should they try next? This is a situation that doctors and patients must confront all the time, so no wonder rheumatologist Jack Cush, MD, a rheumatologist at UT Southwestern Medical Center and executive editor of RheumNow.com, called this study “the best trial from EULAR 2020” in a video about the findings. Researchers took a group of 612 patients who did not have a good response to previous biologic medication and randomised them to either the new JAK inhibitor upadacitinib (Rinvoq), which is an oral pill taken daily, or the infused biologic abatacept (Orencia). All patients continued their background conventional disease-modifying drugs, such as methotrexate.

Researchers found that upadacitinib was more efficacious at helping patients get to low disease activity, but there were fewer adverse events (problematic side effects) with abatacept.

Which treatment to pick “depends on what you want,” explained Dr Cush. If you’re concerned about getting symptoms under control quickly, “you might be swayed by the efficacy data for upadacitinib, but if you’re very concerned about side effects, you might consider abatacept.”

Rheumatoid arthritis patients using TNF inhibitor biologics have lower risk of dangerous blood clots. Anyone can develop a dangerous blood clot, but people with rheumatoid arthritis (RA) face a higher risk than most. While merely having RA can raise the risk of blood clots, studies have also suggested that RA patients with active disease are far more apt to experience blood clots compared to those whose disease is in remission. That means that being on an effective treatment that is controlling your RA inflammation might help reduce your risk of this potentially serious complication.

According to a new study from German researchers, RA patients who use TNF inhibitor biologics are significantly less likely than those using conventional disease-modifying medications (DMARDs) to develop a dangerous blood clot. Read more here about the findings.

Certain factors are linked with an increased risk of interstitial lung disease in rheumatoid arthritis. A substantial portion of RA patients end up developing interstitial lung disease (ILD), a condition that most often occurs when chronic inflammation causes the tissue between the tiny air sacs in the lungs to scar and stiffen. When researchers set out to study which RA patients are more likely to develop ILD than others, they found that people with ILD were more likely to have significantly higher RA disease activity scores, rheumatoid factor and anti-cyclic citrullinated peptide antibodies, chronic obstructive pulmonary disease (COPD), erosive joint disease and rheumatoid nodules. Read more here about the findings.

Yoga improved mood and fatigue significantly in a randomised trial of RA patients. Managing RA often requires more than just being adherent to disease-modifying medication but also making lifestyle changes that can help address things like mood, fatigue and other difficult aspects of living with RA. In this study, 35 patients (average age 55 and average disease duration five years) were randomised to either a 12-week yoga program or arthritis-related educational lectures. Researchers found significant improvements in fatigue, anxiety and depression in the yoga group compared to the control group, although there were no changes in disease activity between the groups. “Despite limitations, our findings suggest that yoga may be of benefit in management of RA patients,” the researchers concluded.

Methotrexate (MTX)

Nausea and fatigue after methotrexate dose is common and related to dosage timing. Nausea and fatigue are commonly reported side effects for this medication, which is widely used to treat rheumatoid arthritis, psoriatic arthritis and other rheumatic conditions. But how do these side effects relate to the timing of the dose, which is typically taken once a week? When researchers from the Global Healthy Living Foundation (GHLF) and CreakyJoints looked at data from 91 patients who had either rheumatoid arthritis or psoriatic arthritis and were currently taking oral methotrexate, they found that there was an uptick in nausea and fatigue symptoms after the MTX dose that then subsided over time before the next dose. Among these patients, 40 per cent had a notable change in nausea symptoms after taking MTX and nearly 61 per cent had a notable change in fatigue symptoms after taking MTX. Read more here about the findings.

Adding caffeine to your methotrexate regimen can make it more tolerable. In an Egyptian study of 60 rheumatoid arthritis patients who had experienced moderate to severe intolerable methotrexate side effects, half were randomised to get an extra dose of caffeine via dark chocolate or coffee. The other half took their medication as prescribed without any extra caffeine. After three months, 80 per cent of the patients who took the extra caffeine reported improvement in their MTX-related side effects. Half of the caffeine recipients were able to stop taking anti-nausea medications, while no one in the control group was able to.

Not taking methotrexate as prescribed has a direct impact on treatment outcomes. “Failing” on methotrexate often leads people with rheumatic conditions to escalate treatment to biologic or other targeted therapies, but sometimes methotrexate doesn’t work as well as it could because patients are not taking it as prescribed. Mexican researchers sought to study this in a group of 795 RA patients; 75 per cent were on oral MTX and the rest were on injectable versions. A significant correlation was found between RA disease activity and methotrexate adherence. (In other words, people who weren’t taking their MTX as prescribed had worse disease activity.)

“Before considering treatment failure in a patient treated with methotrexate, adherence to treatment must be evaluated,” the researchers concluded. “According to our results, self-reported adherence appears to be a cost and time effective method to care for patients.”

Methotrexate does not increase the risk of interstitial lung disease in RA. Though lung disease has been considered a rare but potential side effect of taking methotrexate, this has been disputed and more research has been needed to better understand this.

When a team of international researchers examined the association of MTX exposure with interstitial lung disease (ILD) in 482 patients with RA-ILD and 741 patients with RA without ILD, they found that not only did methotrexate not increase the risk of ILD, it actually was linked with a decreased risk of ILD. Methotrexate used also delayed the onset of ILD.

Psoriatic Arthritis (PsA)

Secukinumab (Cosentyx) did well for psoriatic arthritis skin and joints when compared with adalimumab (Humira). In a “head-to-head” clinical trial, Cosentyx, a biologic that inhibits an immune system protein called interleukin-17 (IL-17), cleared skin better than Humira, a biologic that inhibits the inflammatory molecule tumour necrosis factor (TNF) — and it did just as well treating joint problems.

Rheumatologists commenting on the research suspect that studies like this may start to change which biologics psoriatic arthritis patients receive after they move on from first-line treatment. “Certainly it seems [IL-17 drugs] are better for skin and now we have research that shows they are very good for the musculoskeletal domains,” rheumatologist Arthur Kavanaugh, MD, professor of medicine at University of California, San Diego, said in a RheumNow podcast. Read more here about the findings.

The new JAK inhibitor upadacitinib (Rinvoq) shows promise for psoriatic arthritis. The JAK inhibitor upadacitinib (Rinvoq) became a treatment option in 2019 for people with rheumatoid arthritis (RA) who had not responded well to methotrexate. Now, promising results from two trials indicate it may also be useful in treating both joint and skin symptoms in patients with psoriatic arthritis. Read more here about the findings.

Guselkumab (Tremfya) improved PsA joint and skin symptoms. As part of a trend in proliferating options for psoriatic arthritis, guselkumab, which acts on the immune system molecule interleukin-23 (IL-23), did well in two phase III trials.

Already approved for psoriasis, the medication is likely to be approved by the US Food and Drug Administration (FDA) this summer. “Primary results from the trials showed that treatment with guselkumab 100 mg every four or eight weeks significantly improved joint and skin symptoms over the course of six months,” says Dr Domingues. “After this, placebo-treated patients in both trials were switched to the higher dose of guselkumab, achieving very good responses.”

Psoriatic arthritis patients who responded poorly to methotrexate did better when they added adalimumab (Humira) instead of just increasing the dose of MTX. This is a common dilemma that patients and their doctors face: When to increase the dose of a current medication compared with adding a new medication to the regimen? In a study of psoriatic arthritis patients who had never taken a biologic before and had moderate to high disease activity despite taking 15 mg of methotrexate each week for at least four weeks or more, half were randomised to add the TNF biologic adalimumab (Humira) to their current MTX dose. The other half increased their dose of MTX. They were followed for 16 weeks. Researchers found that “a significantly higher proportion of patients achieved minimal disease activity at week 16 after introducing adalimumab compared with escalating methotrexate. Patients who started taking adalimumab also had significantly higher responses in musculoskeletal, skin and quality of life measures.”

Fatigue is a big problem in PsA, even among patients in remission or low disease activity. A German study confirmed what many psoriatic patients know all too well: that fatigue is very common and has a significant impact on quality of life. Of 105 patients who completed numerous surveys, a clinical exam and lab tests, 53 per cent were classified as having fatigue and another 21 per cent were considered to have severe fatigue.

Most problematic, though, was that fatigue levels were high even among patients considered to be in remission. Sixty per cent of patients studied were considered to be remission based on their disease activity scores, but 38 per cent of them reported high levels of fatigue. “It seems that the clinical routine assessments of disease activity, including laboratory tests and [physician assessments], do not identify fatigue in PsA sufficiently,” the researchers concluded. “Therefore a standardised acquisition of fatigue should be part of studies and daily routine care for PsA patients.”

Biologics may ‘prevent’ psoriatic arthritis in psoriasis patients. An emerging theme in PsA is whether it can be prevented by treating disease activity in people with psoriasis. Argentinian researchers have more evidence to show this may be the case. They looked at nearly 800 patients with psoriasis but not psoriatic arthritis, documented their treatment [whether they used topicals, phototherapy, conventional disease-modifying medications (DMARDs) such as methotrexate or biologic DMARDs] and followed them to see whether or not they developed psoriatic arthritis over time. They found that patients on biologics had a reduced risk of developing PsA compared with other types of treatment.

Skin itching is a problematic symptom for PsA. To better understand how itchy skin — a hallmark symptom of psoriasis — impacts quality of life in PsA patients, Norwegian and US researchers surveyed 125 people with psoriatic arthritis. They found that 57 per cent said they experienced “a little” itchiness, 18 per cent reported “a lot” of itchiness, and 5 per cent said that itchiness was a big problem. After more analyses, the researchers found that itchiness was not associated with the prevalence of skin involvement. In other words, you could have a lesser amount of skin affected by PsA but still feel that itchiness is having a big impact on your quality of life.

Axial Spondyloarthritis (axSpA)

Few non-radiographic axial spondyloarthritis (nr-axSpA) patients wind up with spinal damage over two years. The study, which was led by researchers from Switzerland, aimed to find out whether people with nr-axSpA were as likely as those with radiographic axSpA to develop damage to the spine itself.

(Both radiographic and non-radiographic axial spondyloarthritis cause similar symptoms and disease burden. The difference is that in radiographic cases, damage to the sacroiliac joints can be seen on X-rays.)

It turns out they are not: Hardly anyone who had nr-axSpA at baseline developed spinal damage within two years. Read more here about the findings.

Central sensitisation is common in axial spondyloarthritis — and this could explain why up to 40 per cent of patients who are on biologics still report high levels of pain. Researchers from the Netherlands had people with axSpA complete three different questionnaires designed to assess pain levels and compared them to objective measures of disease activity.

They found that even though patients’ mean disease activity scores indicated they were not in high disease activity, the presence of central sensitisation was very common and that it should be given more attention when a provider is when determining how to best treat patients with this condition. “Pain perception is so important to outcomes,” says rheumatologist Alexis Ogdie, MD, director of the Penn Psoriatic Arthritis Clinic in Philadelphia, Pennsylvania. Read more here about the findings.

Secukinumab (Cosentyx) improved symptoms in non-radiographic axial spondyloarthritis (nr-axSpA). The biologic, which inhibits the inflammatory protein interleukin-17 (IL-17), just became FDA-approved for this condition. Non-radiographic axial spondyloarthritis, which is believed to be part of the same disease spectrum as radiographic axSpA, is starting to gain more approvals. (Another IL-17 inhibitor, ixekizumab, was also just FDA-appoved for nr-axSpA.)

In this study, which compared secukinumab with a placebo, 42 per cent of patients on secukinumab experienced a 40 per cent improvement in disease activity after 16 weeks compared with 29 per cent of patients taking the placebo. After a year, between 35 and 40 per cent of the secukinumab patients were able to maintain that disease activity improvement compared with only 20 per cent of those on the placebo. Read more about the findings from MedPage Today.

A new IL-17 inhibitor, bimekizumab, improved outcomes in ankylosing spondylitis. In a phase II study of 303 adults with active ankylosing spondylitis, led by Désirée van der Heijde, MD, PhD, of the Leiden University Medical Center in the Netherlands, people were randomised to receive various doses of bimekizumab or a placebo and were followed for 48 weeks.

“Results demonstrated greater improvements at week 12 in spinal pain, fatigue, morning stiffness, sleep, disease activity and quality of life in bimekizumab-treated patients than those receiving placebo,” explains Dr Domingues. “Responses were further improved and maintained to week 48.” The drug is not yet approved or available in the US. Read more about the findings from Healio Rheumatology.

Drug-free remission is not common in axial spondyloarthritis. In the biologic era of treatment, remission is the goal for many rheumatic conditions, but drug-free remission in axial spondyloarthritis has not been well-studied. When French researchers looked at 708 axSpA patients, they found only 17 per cent were in drug-free remission after five years. Those who were in remission were less likely to have peripheral joint involvement, had a shorter disease duration and had lower disease activity scores when they were diagnosed. This study “gives us some idea of who can be a good candidate for remission in early axSpA,” said rheumatologist Olga Petryna, MD, in a video for RheumNow.com. “More research is needed to see how feasible it is for patients to stay off their medications long-term.”

High-intensity exercise might control axial spondyloarthritis as well as biologics. AxSpA patients were randomly assigned to participate in a supervised exercise program or take a TNF inhibitor biologic (a targeted medication that reduces inflammation). Disease activity was assessed at baseline and again three months later. According to the authors, “there were no significant differences in change in disease activity at three months between patients participating in [the exercise intervention] and patients starting a TNFi.” They concluded that “high-intensity exercise has comparable three-month effectiveness to TNF inhibitors in patients with axSpA. This confirms the important role of high-intensity exercise in the treatment of axSpA.” Read more here about the findings.

If you have inflammatory bowel disease (IBD) and joint pain symptoms, the biologic vedolizumab may not work as well to control joint symptoms. As rheumatologist Jack Cush, MD, explained on RheumNow.com, IBD patients may switch from a TNF inhibitor biologic to other therapies, such as vedoliziumab (Entyvio). Spanish researchers looked at a group of 61 patients, 20 per cent of whom had a history of IBD-related spondyloarthritis. Of these, one-quarter experienced a joint pain exacerbation within five months of starting vedoliziumab.

“Although the response was good for bowel disease, more than 25 per cent experienced flares from joints,” says Dr Domingues. “Given that vedolizumab is mainly absorbed locally in the gut, I see this as a potential issue for our patients with mixed disease with both articular and intestinal manifestations.”

AxSpA takes a big toll on patients’ sex lives. In an online survey of more than 2,500 patients with axSpA (61 per cent female, average age 44 years) across 13 European countries, people answered questions about how their intimate relations changed since they started experiencing symptoms. More than half (56 per cent) said it was “less or much less than before,” 74 per cent said they had “high or medium limitations in intimate relations,” and 30 per cent reported worsening relations with their spouse.

Gout

Gout attacks commonly affect tendons, such as behind the ankle and kneecap. In a Chinese study, researchers performed ultrasounds on 31 gout patients during acute attacks to look for involvement of entheses, which is tissue that connects ligaments or tendons and bones. They found that 71 per cent of patients showed abnormalities with at least one enthesis, with the most common areas involving the Achilles tendon behind the ankle and the tendon just below the kneecap. This could be a missed opportunity for diagnosing gout sooner.

“People with gout who get pain and swelling in the Achilles’ tendon, for example, may think it’s a tendon strain or other tendon injury, but there is a good chance it is a gout flare and will respond to gout treatment,” says Dr Fields. Read more here about the findings.

Physical activity is linked with fewer gout flares and less inflammation. Researchers from the Rutgers Robert Wood Johnson School of Medicine in New Jersey and The Ohio State University Wexner Medical Center found that gout patients who were physically active (based on their responses to a survey called the International Physical Activity Questionnaire, or IPAQ) had more than 12-fold fewer gout flares per year as well as dramatic decreases in C-reactive protein (a measure of inflammation) and self-reports of pain compared with people who were inactive. The finding highlights the “importance of incorporating physical activity as a possible adjunct treatment option during intervals between flares,” say study authors.

Gout patients who visit the emergency department for flares miss an opportunity to get on better treatment. A gout flare can be one of the most suddenly painful experiences — many patients say even brushing their toes against a bedsheet is intolerable. It’s no wonder, then, that many people visit the emergency department to get help for a gout flare. But data from Rutgers researchers in New Jersey found that nearly 30 per cent of gout patients are discharged from the emergency department without an anti-inflammatory medication (which is the first-line choice for treating a flare). As well, initiation of urate-lowering therapy, such as allopurinol and febuxostat, was rare.

“Treatment of gout in the [emergency department] is sub-optimal and often does not follow established guidelines,” the authors concluded. If you visit the emergency department for a gout flare, that’s a good sign you should be following up with the primary care doctor who treats your gout (such as an internist or rheumatologist) to look at your treatment and decide whether a change is needed.

Taking methotrexate with pegloticase (Krystexxa) may make gout treatment more effective. Pegloticase (Krystexxa) is an infused medication that is used to treat uncontrolled gout, in which patients who keep getting flares despite being on uric acid-lowering treatment. Approved since 2010, its success has been limited because many people develop infusion reactions or antibodies against the drug, which makes it intolerable or ineffective. Now, in two preliminary studies, patients’ response to pegloticase was found to improve when the immune-modulator medication methotrexate (MTX) was given both before and throughout the infusion treatment. Read here about the findings.

Rheumatoid arthritis medication anakinra (Kineret) continues to show promise in gout. During an acute gout attack, patients often take non-steroidal anti-inflammatory drugs like NSAIDs or colchicine to reduce pain quickly. But for those who can’t take those medications, research shows a biologic medication called anakinra, which inhibits an inflammatory protein called interleukin-1 (IL-1), can be an effective option. In the study, run by a research team led by Kenneth Saag, MD, of the University of Alabama at Birmingham, patients with difficult-to-treat gout were randomised to receive either five days of 100 mg or 200 mg of anakinra, which is injected under the skin, or a one-time dose of an injectable steroid drug called triamcinolone. Pain levels were comparably reduced in both groups (there was no difference between the two dosages of anakinra). Patients on anakinra did slightly better than those on triamcinolone on some other measures.

“This represents a potential new weapon for the management of gout,” says Dr Domingues.

Patients with gout and diabetes have a high rate of amputations compared to healthy adults. Researchers analysed data from a large US claims database (190 million adults) to understand the rates of amputation in four groups of patients: those with only gout, those with only diabetes, those with both gout and diabetes and healthy people with neither condition. They found that patients with gout but not diabetes suffered an approximately three-fold increase in amputations compared to patients without either disease. Additionally, patients with both gout and diabetes had a notably increased risk of amputation compared to patients with only diabetes.

“This emphasises that gout on its own is a [serious] condition and when it occurs together with diabetes it can put patients in great danger,” said Dr Petryna, MD, in a video for RheumNow.com. “It requires strict uric acid control in patients who have both conditions, and aggressive treatment.”

Losing weight has a modest impact on uric acid levels in obese adults without gout — and the diabetes drug liraglutide helps even more. Because of the known relationship between gout and obesity, Danish researchers sought to study the effect of weight loss on blood levels of uric acid. They took 156 adults who were obese and had knee osteoarthritis — but did not have gout — and offered them an intensive eight-week diet intervention designed to promote weight loss (800 to 1,000 calories a day), then randomised them to a yearlong weight maintenance plan. Half would get a placebo and half would get liraglutide, a medication often used to treat diabetes that is also known for causing weight loss. The group lost an average of 27.5 pounds during the first part of the study. Those on the medication lost an additional nine pounds on average, while those on the placebo maintained their weight loss.

As for uric acid, the intensive diet led to a drop of 0.21 mg/dL on average, but in the following year, the liraglutide group dropped another 0.48 mg/dL on average. The authors concluded that “liraglutide provides a potential novel serum urate-lowering drug mechanism in obese patient populations, with potential implication for gout treatment.”

Lupus

Poor sleep quality in lupus is highly prevalent and deserves more attention. In a study of 92 lupus patients from Malta, 55 per cent reported having poor sleep quality. Patient factors that predicted poor sleep included pain levels, depression and impaired kidney function. “Since poor sleep quality is significantly related to fatigue and functional disability, its identification and management is important for patients’ wellbeing,” the authors concluded.

Lupus patients’ self-reported symptoms don’t improve within the first few years of being diagnosed. When you track patient-reported outcomes (PROs), you learn more about the burdens of disease on patients’ everyday lives. Swedish researchers set out to compare PROs among people with rheumatoid arthritis and lupus over the course of five years from when patients were diagnosed. They found that while RA patients reported worse scores initially, they began to improve by six months. However, for lupus patients, their scores remained relatively steady throughout the study period — they did not improve over time.

“The lack of improvement in [PROS] in patients with SLE may be due to the disease’s impact across multiple organ systems, which may take longer to resolve versus RA symptoms,” the authors concluded.

Voclosporin beat standard treatment for lupus nephritis. According to RheumNow.com, voclosporin, a type of drug called a calcineurin inhibitor that has performed well in an earlier phase II clinical trial, significantly outperformed routine therapy (mycophenolate) for lupus nephritis, or lupus that has caused kidney damage.

In the trial, 357 patients with active lupus nephritis stayed on background treatment of mycophenolate and then were randomised to get either voclosporin or a placebo. A measure of kidney function called renal response was seen in 41 per cent of patients on voclosporin but only in 22 per cent of those on the placebo.

High renal responses on the medication were also seen in Hispanic and black patients, who can have more severe and hard-to-treat lupus nephritis. For example, renal responses among Hispanic patients were seen in 39 per cent of the voclosporin group after one year compared with 19 per cent of controls; renal responses were seen in 46 per cent of black patients on voclosporin compared with 16 per cent of controls. Read more about the findings from MedPage Today.

Belimumab (Benlysta) with standard therapy improves lupus nephritis treatment. In more promising news for lupus nephritis, the already-approved lupus medication Benlysta proved to be particularly efficacious in patients with kidney disease, says Dr Domingues. “It’s very important for the lupus community to have a familiar option with known safety,” he says.

In the study, a two-year, randomised and double-blind trial (so neither researchers nor patients knew who was getting which medication), 448 patients with active lupus nephritis were randomised to get belimumab or a placebo alongside standard immunosuppressive treatment (some were on cyclophosphamide followed by azathioprine and others were on mycophenolate mofetil (MMF). Forty-three per cent of the patients on belimumab had improved renal response compared to 32 per cent of patients on the placebo medication. Importantly, “belimumab-treated patients had a significant 49 per cent lower risk of a renal-related event or death at any time point during the study compared with placebo recipients,” reported Rheumatology Advisor.

Too-little hydroxychloroquine in the bloodstream raises the risk of blood clots in lupus. An increased risk of blood clots in the lungs or the deep veins of the legs is just one of the many medical issues that can accompany the autoimmune condition lupus — and it is well-known that the first-line lupus medication hydroxychloroquine (HCQ) reduces the thrombosis [blood clot] risk in lupus, according to Michelle A Petri, MD, MPH, a professor of medicine at Johns Hopkins University, in a presentation at EULAR. In a new study, Dr Petri and colleagues sought to understand how having the right dosage/blood levels of HCQ affects the risk of blood clots.

They found that rates of thrombosis decreased by 13 per cent for every increase of 200 ng/mL in mean hydroxychloroquine in the blood. Importantly, the researchers found that the dose of HCQ you are prescribed does not predict what your blood level of HCQ will be, which suggests that the best way to personalise the dose for maximal protection against clots is to monitor whole blood HCQ regularly and adjust the dose as needed. Read more here about the findings.

Lupus patients are at a higher risk for an antimalarial-induced retinopathy. While first-line lupus medications hydroxychloroquine and chloroquine can be lifesaving for patients, their dosages do need to be balanced with a risk of a type of eye damage called retinopathy. Compared with people on these medications for other medical conditions, such as rheumatoid arthritis, patients with systemic lupus erythematosus (SLE) had a greater risk of retinopathy, possibly due to prolonged exposure to those drugs, according to a new study from Canadian researchers. It is critical to work with a rheumatologist and ophthalmologist when you’re taking these drugs to strike a balance for effective dosing while monitoring for eye damage. Read more here about the findings.

Osteoarthritis (OA)

Osteoarthritis is often followed by other health issues, such as depression, heart disease, diabetes and more. A large Swedish population study set out to study what conditions people tend to get diagnosed with after they receive a diagnosis of hip or knee osteoarthritis. They studied 36,465 people with knee OA and 14,477 with hip OA and compared them to adults without any OA diagnosis. They found that people with osteoarthritis had an increased risk, compared to the general population, of seeking health care for depression, cardiovascular disease, back pain and osteoporosis.

“Considering the high prevalence of osteoarthritis in most parts of the world, such information is needed for better patient care,” said study co-author Martin Englund, MD, PhD, in EULAR Congress News. He said it is important for rheumatologists to regularly assess osteoarthritis patients for other conditions. “We recommend clinicians to evaluate the ‘whole’ patient when seeing an osteoarthritis patient in daily practice. In particular, be aware of signs or symptoms of undiagnosed cardiovascular diseases, as well as consider diabetes screening,” he said.

Weight may play a role in hand OA pain. While being overweight or obese is a known risk factor for osteoarthritis, in part because carrying extra weight places stress on weight-bearing joints like those in the knees, ankles and feet, less is known about how one’s weight affects hand osteoarthritis pain.

In a Norwegian study, 300 patients with hand OA answered surveys about their pain, their pain was also assessed in a physical exam, and they had ultrasounds of their hands, feet and knees to look for synovitis, or swelling and inflammation of the tissue surrounding a joint. The researchers found that people with higher body mass index (BMI) and waist circumference reported higher pain intensity in their hands, feet, knees and hips — and this was not explained by higher levels of synovitis in the joints. While the authors can’t conclude a definite explanation, they suspect that the link “may at least partly be driven by a higher prevalence of central pain sensitisation in persons with higher BMI.”

More research just showed that hydroxychloroquine is not effective for erosive hand osteoarthritis. This drug has a proven track record of helping patients with autoimmune conditions including lupus and rheumatoid arthritis, but some doctors have also been using hydroxychloroquine to treat select patients with osteoarthritis (OA), even though it is not officially approved for this purpose. In a new study, researchers from Germany randomly assigned patients with erosive hand OA to take 200 to 400 mg of hydroxychloroquine each day or a placebo for 52 weeks. Everyone in the study also took an NSAID (non-steroidal anti-inflammatory drug), which is standard therapy for hand OA. After the study ended, there were no significant differences between the two groups. Read more here about the findings.

Emotional response to pain plays a role in knee osteoarthritis and even the need for knee replacement surgery. A study out of Spain looked at patients with knee osteoarthritis, some of whom had knee replacement surgery and others who were trying conservative treatments for knee pain. The researchers had the patients fill out a number of questionnaires to assess pain as well as emotional components related to it, such as surveys about depression and pain catastrophising (when you tend to focus more on pain or feel more helpless about your ability to control it than average). The patients were assessed by a physical exam, ultrasound, and had their blood taken to look for levels of inflammation. The researchers found that there is not always correlation between a patient’s pain symptoms and the status of their joint health — and that emotional factors could explain this discrepancy.

“Working out strategies for pain management could improve [pain catastrophising] and therefore reduce the need for total knee replacement,” the authors wrote.

Osteoarthritis can have dramatic impacts on mobility and the need for assistance with daily activities for those with moderate to severe pain. A team of researchers from the University of Leeds in the UK grouped 1,750 osteoarthritis patients into three groups — mild, moderate and severe pain — based on patients’ self-assessments and assessments from their physicians. They found dramatic differences in mobility and the need for help with daily activities by group. Mobility was impacted for 78 per cent of patients with severe pain, compared with 41 per cent of patients with mild pain. Nearly one-third of patients with severe pain had to modify their home due to their OA, compared with 11 per cent of people with mild OA. And 42 per cent of people with severe OA required help from a caregiver for daily activities (such as help with shopping, cooking or travelling out of the home) compared with 9 per cent for mild OA.

“This study highlights the substantial need for assistance with daily activities as well as modifications to the home,” write the study authors. “The unseen costs to the patient with moderate to severe OA pain are significant.”

Fibromyalgia

Many fibromyalgia patients have symptoms consistent with axial spondyloarthritis. Fibromyalgia is often challenging to diagnose and treat because it frequently occurs alongside other chronic diseases. One common area of confusion has to do with fibromyalgia and axial spondyloarthritis (axSpA). For a variety of reasons, doctors suspect that axSpA goes undiagnosed in many people who have symptoms of it.

Researchers, including those from our non-profit organisation, the Global Healthy Living Foundation (GHLF), set out to learn more about this potential overlap by surveying 231 patients who reported a diagnosis of fibromyalgia in our ArthritisPower research registry.

They found that while only 40 people reported also having a diagnosis of axial spondyloarthritis, many patients with fibro and without an axSpA diagnosis reported having symptoms consistent with those of axSpA. In fact, a full 12 per cent of fibro patients in the study reported having all of the symptoms consistent with patient-reported versions of a set of common criteria for axial spondyloarthritis. Read more here about the findings.

Water- and land-based exercise helps fight fibro fatigue, but it’s important to stick with a regular routine. Researchers wanted to understand whether doing land or water-based exercises lead to a difference in fatigue in people living with fibro. After they randomised patients to two different workout regimens (which involved exercise classes three days a week for six months) and a control group, they found that both water exercises and land exercises had significant impacts on fatigue reduction. However, when participants stopped following the program and were evaluated another three months later, the benefits were not sustained. The researchers concluded that “participation in regular exercise” can help manage fatigue in this population.

Vitamin D can help support fibro treatment in patients with low levels of the vitamin. In an Egyptian study, researchers randomised 100 patients with primary fibromyalgia (meaning they did not have another co-occurring condition such as rheumatoid arthritis) and who were vitamin D deficient based on blood tests into two groups. One was given the antidepressant medication duloxetine (Cymbalta) plus prescription vitamin D supplementation; the other got just the duloxetine and a placebo. After six months, blood levels of vitamin D improved significantly in the treatment group, as did their scores that assessed functional status, quality of life and psychological status. “Vitamin D supplement is effective as an adjuvant therapy … in fibromyalgia patients with vitamin D insufficiency,” the researchers concluded.

Mental Health, Wellness and More

Rheumatoid arthritis patients who see nurse practitioners fare just as well as those treated by doctors. To find out whether nurses with extra training in rheumatology might be able to provide care in lieu of rheumatologists — and thus reduce very long wait times to get appointments — researchers took 236 rheumatoid arthritis (RA) patients and randomly assigned them to two groups. Half had regular checkups with a rheumatologist and the other half had their appointments with a rheumatology nurse practitioner instead. The researchers found that patients who saw a rheumatology nurse fared as well as those who saw a rheumatologist (doctor) in terms of disease activity scores and patient-reported measures of daily functioning, quality of life and depression. Read more here about the findings.

It is important for rheumatic disease patients to track measures of pain, fatigue and joint stiffness. Patient-reported outcomes (PROs) are typically short surveys that assess various health symptoms, such as pain, fatigue, sleep and more. Not only are they a very important tool for measuring and monitoring disease, but they are also important during clinical trials for medications or other treatments, as they can assess how different therapies affect patients and the symptoms that matter to them.

The Global Healthy Living Foundation (GHLF) and CreakyJoints have started studying which PROs matter most to arthritis patients. When patients were asked to pick a number of symptoms to track for three months and then rank which ones seemed most important to track, the top five included surveys that assessed fatigue, physical function, pain intensity, pain interference and joint stiffness duration. Read more here about the findings.

Managing mental fatigue is particularly important for rheumatic disease patients who work.

Almost 65 per cent of people with rheumatic diseases have severe fatigue, with the majority of these reporting difficulties in work leading to absenteeism and early retirement, note Irish researchers, who sought to study how different types of fatigue (general, mental, physical, reduced motivation and reduced activity levels) affected people’s ability to work. They surveyed 234 people with rheumatic conditions who were currently working. While physical fatigue was the most common kind, the researchers found that having mental fatigue was the most significant predictor of difficulty meeting work demands. “

Self-management interventions focusing on mental fatigue and work ability are required for individuals with rheumatic diseases to manage the demands of their work,” concluded the researchers.

Depression is common and underdiagnosed in patients with rheumatic disease. Italian researchers sought to study the presence and the perception of depressive symptoms in patients with different kinds of rheumatic diseases. After they surveyed 192 patients, they found that only 18 per cent were not depressed. Although they determined that about 35 per cent of patients had sub-clinical or mild depression, 22 per cent had moderate depression, and 25 per cent had moderately severe or severe levels of depression, only 8 per cent of people themselves “declared to have depressive symptoms,” which shows that depression largely undiagnosed in this patient population.

“These results highlighted that depressive symptoms are overlooked by physicians and unperceived by patients,” the researchers concluded. “These results suggested that screening for depression should form part of the routine clinical assessment of RD patients.”

Lifestyle changes are instrumental in managing rheumatic conditions. EULAR presented recommendations for healthy lifestyle strategies to prevent progression of rheumatic and musculoskeletal diseases, Healio Rheumatology reported. While nothing is particularly surprising — do aerobic and strength-training exercises, eat a balanced diet, talk to your doctor about the ideal weight for you and adjust medication doses when people gain or lose weight, have alcohol consumption be moderate and limit alcohol if you have gout, quit smoking — it is impactful to see major medical organisations emphasising the importance of lifestyle changes to complement medical treatment.

How You Can Access the EULAR 2020 E-Congress Sessions Online

One of the benefits of holding the EULAR 2020 congress as a virtual event is that all the sessions were recorded and they can be accessed by patients, researchers and health practitioners around the world. All you need to do is register as an attendee by 31 August 2020 and you will have access to the sessions until 1 September 2020. Whatsmore, patients can register for free (providing you upload a doctor’s letter confirming your diagnosis).

For many people, this will be the best opportunity you will ever have to attend a EULAR congress, so why not make the most of it?

Found This Research Helpful? Get Involved

If you are diagnosed with arthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining CreakyJoints’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centred research registry for joint, bone and inflammatory skin conditions. Learn more and sign up here.

Further Reading

• Arthritis Treatments
• Living With Arthritis During COVID-19: Education and Support Resources
• 5 Ways Your GP Can Help You Manage Your Chronic Illness
• Living With Arthritis: General Articles
• Raising the Voice of Patients: A Patient’s Guide to Living with Rheumatoid Arthritis in Australia