Panel Discussion with Associate Professor Frederick Joshua, Professor Sam Adie and Dr Mustafa Alttahir.

In this episode, we welcome Associate Professor Samir Viswanathan to moderate a panel discussion with experts Associate Professor Frederick Joshua, Professor Sam Adie and Dr Mustafa Alttahir on the complex world of inflammatory conditions such as rheumatoid arthritis, psoriatic arthritis, and lupus. The conversation begins with an exploration of diagnostic markers and the role they play in primary care, revealing that while 70-80% of rheumatoid arthritis patients present with biological markers, the diagnostics become murkier with conditions like psoriatic arthritis. The discussion sheds light on the limitations of blood tests and emphasizes that understanding patient history is equally critical in forming a diagnosis.

We then shift gears to discuss the management of treatment protocols for patients undergoing surgery while on DMARDs and biological agents. The experts share their insights on how and when to halt these medications pre-operatively, underscoring the general guideline of stopping conventional drugs like methotrexate a week before surgery, while biological drugs may require a longer cessation period. The discussion balances medical protocols with practical implications, noting that surgical infection rates are low, allowing for a more seamless transition to restarting medications post-operation.

Addressing pain management strategies, the panel engages in a candid dialogue about the analgesic ladder for arthritis-related pain and the rising concerns about opioid usage. The conversation challenges the prevailing negative perception of anti-inflammatories, countering the fear that they may adversely affect kidney function. The expert panelists argue for rational use of anti-inflammatories, advocating for them as viable alternatives to opioids, especially given recent findings highlighting their efficacy. This discussion culminates in upcoming research aimed at exploring opioid-sparing strategies for pain relief in hospital settings.

As the conversation progresses, the importance of patient-reported outcomes is emphasized, especially when it comes to managing vague symptoms and the potential anxiety that positive autoimmune markers can instigate. The panelists highlight the necessity for shared decision-making and individualized monitoring, advising that patients with mild symptoms may not require immediate referral, while those exhibiting discernible dysfunction or systemic complications should be prioritized for specialized care.

The dialogue inevitably leads to specific queries regarding steroid injections in various joints and the criteria for their administration. With a statistic of one in 400 for infection risk, the panel reassures listeners of the relative safety of knee injections compared to surgical options, outlining circumstances under which to consider such treatments. This part of the discussion highlights practical guidance for physicians on managing patient expectations and the nuances involved in guiding treatment options based on observed joint conditions and patient history.

This session not only sheds light on the intricacies and evolving landscape of treating arthritis and related autoimmune conditions but also reinforces the importance of collaboration among medical experts to improve patient outcomes.

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So I'm going to invite Associate Professor Samir Viswanathan up to moderate

the panel discussion and our panellists, if you wouldn't mind taking a seat.

Thank you. And somehow.

And ladies and gents, as I mentioned at the beginning, you will be able to submit

questions via the Slido app using the QR code on your agenda if you'd like,

or Liesl and I will be walking around with the microphones as well.

So, to start off.

Thanks, Fred, Sam and Mustafa. So, we'll start off with the first question.

What percentage of those presenting in primary care with evidence of inflammatory

polyarthropathy have biological markers which assist in diagnosis?

I guess that's to you, Fred. Yeah, 70 to 80%.

So it's about 20% that have less than that in terms of trying to prove a diagnosis.

So it's not infrequent, but it is.

So if you're using blood testing, then you won't see much blood testing in psoriatic arthritis.

So that's the drama. But for rheumatoid, it's quite high, 70% to 80%.

For lupus, it's 99%. And for psoriatic arthritis, that's the harder bit because

you won't have blood test proof, but you'll have historical proof.

Fred can I ask a question on behalf of the orthopedic surgeons when do you stop,

you know DMARDs and biological agents before surgery and when do you restart?

Before surgery it's usually around the half life but for conventional synthetic

drugs so methotrexate luflunamide, plaquenil, hydroxychloroquine,

those drugs a week before is fine for biologic drugs it depends on the drug

but generally you'll go for, say, the drug lasts a month.

So for golimumab is a monthly injection, stop a month before.

For TNF blockade, some of them, again, it's another TNF blocking drug,

is a tanacep, that's a week.

So it depends on the drug, but generally it'll be the half-life of the drug.

And then starting after, because the complication rates from all of the surgery

you guys do is really quite low, like you don't get many. Thank you.

No, really. Like it's unbelievable what people do.

And so the surgical infection rate is so low that generally you can start a week later.

So once the surgeon says to me, you're fine, which is usually five,

seven days, you can just get started again.

Fantastic. Another question. What level of ANA is considered positive in SLE?

So it depends on the time of the, oh, sorry, the age of the patient.

So a baby, they shouldn't have a positive ANA. So as age increases,

the ANA frequency increases.

So it depends on that a little bit. But most of the time, like in a baby, it'll be one in 80.

But in an adult, say a middle-aged person, it'll be one in 640.

And then because lupus and other connective tissue diseases are like a jigsaw

puzzle, You want pieces of the puzzle to make the diagnosis.

You may accept a slightly lower ANA and then it sort of fits together.

So ANA on its own doesn't mean anything really.

It's all in association with the other symptoms.

Some connective tissue disease markers are more likely to be indicative of future

development of disease than others.

So an ANA on its own will not be a predictor of future disease,

but something like an anti-centromere antibody, that has a higher frequency

of developing into limited scleroderma, those sort of issues.

So it's a little bit contextual, but an ANA 1 in 640 would be reasonable to

consider that this is probably pathogenic in a person who has appropriate symptoms,

but heaps of people have blood tests with abnormalities, heaps,

without it being indicative of disease.

So the next question I I think all of us can answer. What is your analgesic

ladder for managing arthritis-related pain?

So, there are guidelines for this. So, I guess the gist of it is that you just

start off with the simple stuff first.

So, Panadol, Panadol, Osteo, and anti-inflammatory.

And then, if they don't work, then you sort of move up to, I guess,

the more, you know, the stronger stuff, the opioids.

If we're talking about sort of a chronic condition like arthritis,

someone's going to need to be on those for quite some time.

Generally speaking we should stay away from the longer

acting opioids i don't think they are

recommended anymore particularly for acute flare-ups or any sort of acute problem

including surgery i think there's been a strong move now to sort of like just

delete them completely from the management of at least acute pain but i would

argue also for chronic pain we should probably,

disencouraged the use of the, because they've just been associated with,

I guess, more of the problems of dependency and addiction and side effects, et cetera.

And the only other comment I make, sorry, I'm just hijacking this because it

is something that's close to my heart, is there seems to be this really negative

view of anti-inflammatories.

Every single patient that I come across.

And you say, oh, you should take an anti-inflammatory. And they go,

oh, no, no, no, I can't take an anti-inflammatory because it's going to kill my kidneys.

Or, you know, it's going to be so dangerous.

And I'm getting to the point now where I think this is some sort of like.

You know, marketing campaign by the opioid companies where they've got like,

they're just feeding all of this like false information to doctors and patients

about how terrible anti-inflammatories are.

And we know from studies that you can be on them for

like months and months and months and with very

little you know problem and the side effects are

very very rare and they do work right so

um and in some studies suggest that they work almost just as well as opioids

um in fact it's gotten to the point now where we're just about to do a randomized

trial where we're randomizing people to completely deleting the opioid medication,

so opioid sparing medication approach.

So it's going to be just Panadol and an anti-inflammatory versus something with

an opioid, a combination with opioids for people with acute fracture, right?

So you can imagine that that's a pretty significant presentation, right?

People leaving the hospital, recovering from their acute fracture.

We want to show or we want to see if people have as effective pain relief if

we just delete the opioids altogether.

Because every study that comes out, we're seeing more and more now that the

opioids are actually probably not as effective as what we thought they were.

Yeah. Do you remember the answer?

I generally add the COX-2, yeah. I'll just add to that.

I think if a patient is needing opiates for arthritis, I think that is a sign

that they're probably needing some sort of intervention.

I think my sort of general preference is getting them to Panadol,

Ostea regularly, Meloxicam or Ocelococcip regularly,

and then if that isn't helping injections, so getting them to have a corticosteroid

injection generally as a first line.

If they're a little bit reluctant, they can try the hyaluronic acid injection or the PRP.

But if they're starting to get onto the opiate treatment, I think that's the

point where they're probably not, I agree with Sam, I think dependence is an

issue And I think at that point, we should be considering surgical intervention.

Obviously, if it's very intermittent opiate use, then, you know,

they can probably have one end done in a blue moon.

But if they're needing end done every day, multiple times a day,

that's probably a sign that they should have surgical intervention if there

is a surgical option available for them. Just a quick question.

The question about, with a patient of mine who's on methotrexate,

doesn't want to go to the biologics, would we use plaquenil instead?

And also folinic acid, where does that come into?

So plaquenil is much safer, hydroxychloroquine is much safer than methotrexate.

Changing someone preoperatively to move on to something like hydroxychloroquine,

it doesn't work quickly enough.

And so we often won't switch but if we want

a lighter agent hydroxychloroquine's much better folinic

acid um i utilize that because a

bit of a hassle it's a bit more expensive so i utilize folinic acid when people

have intolerance to folic acid for whatever reason sometimes people feel a bit

funny about it um and also for hair loss sometimes people getting some hair

loss and i might give them folinic acid at that point um and it is much more

and is crucial in rescue therapy.

If someone overdoses on methotrexate, et cetera, then you can,

you generally use fulinc acid.

And I just wanted to follow up with the guys about what they commented around pain relief.

Completely appropriate. That's what the strategy should be to avoid narcotic analgesia.

And if you can think that anti-inflammatories are a disaster,

think about methotrexate. Every man and his dog is saying, don't do it.

And so it's quite problematic, but we get that a lot as well.

I can't use anti-inflammatories, but trying to avoid in longer term pain relief

for people who have problems from inflammatory disease and maybe secondary fibromyalgia

or other centralised pain syndromes,

I think getting the pain specialist involved is really quite useful.

And for joint areas, we might also involve them for blocks, et cetera.

So even sometimes people will have some pain post-operatively and they may benefit

from a geniculate nerve block, for example, in the knee.

And that can be done even if people have had some funny knee reaction after

a surgery where they've continued pain.

It doesn't work as well for preventing joint damage. So if you can get away

with hydroxychloroquine for reducing

cyanobitis and they don't have joint damage, then yes, it is better.

But the reason we start with methotrexate and rheumatoid is much more effective.

And time to, the earlier you treat and the faster the remission,

the lower your drug needs in the long term are.

So it's all about speed. A bit like cancer, hit hard, hit early,

fix, move on. And then you can reduce.

This one's for Mustafa. Can you please summarize the tibial and femoral osteotomy

for medial and lateral arthritis? Which one is which?

So for varus, if they're bow-legged,

generally the tibial-sided correction, so HTO for varus alignment,

and we make the patient valgus by about three to six degrees.

For valgus if

they're not neat we do a distal

femoral osteotomy and often you don't

do as much of an overcorrection so probably one

to two degrees of varus so varus

is hto and valgus is dfo which is distal femoral so um i'm not sure if that

uh is that that's great answer um steroid injection into the hip and if steroid

injection is given how soon can surgery be done sam,

Traversial. So, good question.

So, my personal view versus some of the maybe, you know, college statements that are coming out,

my personal view is it shouldn't be a hard and fast rule about restricting people

from having surgery after they've had an injection.

I think the evidence linking problems with people having injections to post-operative

complications is weak It is really sort of observational evidence when you think

about it People who are going to have more injections are probably more likely

to have more severe problems,

More reasons why they might be in pain.

The joint itself is probably in a worse state you can see why those people will

probably have a higher rate of complications.

There's a whole bunch of confounders here about why that person may have,

you know, a higher rate of post-op complications. It's not just the injection.

But on the other hand, restricting people from having surgery,

particularly if you work in a public system and,

you know, you're trying to get these people over the line and then their public

surgery, you know, date rocks up and they go, oh, no, no, no,

you can't have that surgery because you've just had an injection like a month

ago and then they have to go to the back of the list or delay them for another few months.

No, that's just bullshit, sorry, because that person really needs that surgery

because they're struggling, they need to have that treatment.

So for me, I'm much more circumspect about it, okay? I don't think there's a very strong link.

If someone has very mild symptoms and can be delayed, then yes,

you should probably delay a little bit.

In any case, you should probably just discuss it with the patient so that they're

aware, okay, that whole sort of shared decision-making model approach, right?

I've got two questions. One is the methotrexate. How long before you stop if

people want to fall pregnant and what do you substitute with?

So three months for pregnancy.

And so remember fathering children, you can just go through, it's not a big deal.

Three months and then substitution is with, depending on the illness,

but hydroxychloroquine is good in pregnancy.

Sulfosalazine is good in pregnancy. Biologics, TNF blockade is good in pregnancy

and some of the other biologics are likely to be also safe in pregnancy, but less clear.

And you can also use cyclosporine. So there are other agents that are safe in

pregnancy if people are flaring.

Other question is that you all say to put on people on anti-inflammatory,

but what happens with those people who are already on Noyak or Plavix?

Do they have an increased risk of bleeding?

They do have an increased risk of bleeding. And so anti-inflammatories do have

risks. So we can't pretend that they're perfectly safe, but they're pretty safe

because they're, you know, you can buy them over the counter.

And so we know that it's pretty safe and you can risk stratify.

So somebody who is taking other anticoagulant drugs, so if they're on apixaban

or eloquence, you shouldn't really do it because there is an increased rate

of bleeding in those situations, but you might factor in that and very occasionally.

If they're on warfarin, similarly. If they're taking other aspirin and Plavix

together, you're increasing the risk of bleeding, but you can mitigate that

a little bit with anti-ulcer drugs.

So it does come down to what person is, and that sort of person who's also on

an anticoagulant agent is likely to have ischemic heart disease,

is likely to have ulcer risk, is likely to have vascular problems and kidney disease.

They're not the right patient in general anyway, and that's what we're talking

about. well, we probably should think about surgical solutions to give them longer-term relief.

Or we say, look, anti-inflammatories may not be perfect, so we'd better get

your pain specialist help to try and work at other methods.

You mentioned in terms of autoimmune markers, and often they're positive,

but they don't have the clinical symptoms and they don't fit the diagnosis.

So what's your sort of, I guess, take on that in the sense that do you just

monitor these patients?

Should we be referring to a rheumatologist? We just monitor ourselves.

Yeah, look, it's complicated because I think you've got to use patient-reported outcomes.

So if somebody's really struggling and they can't do things,

we've got to think why aren't they able to do things? And then that person is

appropriate for referral.

So the other component is if they've

got some sort of organ system damage that's also causing a problem.

So being aware that maybe they're getting erosive disease and their blood tests

are not showing it and that's because they've got a spondyloarthritis.

Or I'll see people who are really functionally impaired, recurrent pericarditis.

Sometimes that will lead to constriction, but blood markers don't show anything.

And I think factoring out that blood is one metric, so blood is one thing.

Patients saying something is something.

Examination is something. The investigative tool that we show is also something.

And then not delineating and saying, well, because someone's complaining that

that isn't important. It is because they are also needing a solution.

So finding the appropriate solution, depending on the level of risk and harm, is probably the key.

But if somebody can manage, and they have no organ problem, so nothing that's

leading us to think they're going to have a significant issue,

then we can relax more and monitor.

But people feel very validated by hearing that you can understand that they're

struggling and we're recording this. And as they continue to record that problem, we may take more risk.

Yeah. And that's the problem. Because I guess there are a lot of people who

get these autoimmune screens done for various reasons.

Sometimes it's very vague complaints and you sort of do the autoimmune screen

thinking, oh, let's just exclude everything.

And then boom, the CCP is positive, but they don't have any clinical manifestations of RA.

So those people who then you say, hey, your CCP is positive,

obviously would get highly anxious but they don't have clinical symptoms of

rheumatoid, do you expect them

to then develop it over some period of time when it's highly specific?

Yes, so if you have a clinical syndrome that suggests that you have painful

joints to warrant the test for the CCP antibody.

And over the next two years, you are a 50% chance of developing rheumatoid with

a positive rheumatoid factor,

knowing that if you have a viral infection or some other problem,

you can develop a low-level CCP antibody.

But if you're doing the test, you're also doing it because they had something

that made you want to do it.

And so you can watch and see. But if they're continuing to have symptoms,

and if you did an MR or you did an ultrasound and you found inflammation,

then you can say maybe this person has an inflammatory syndrome.

So it's sort of checking more thoroughly and then saying, okay,

this CCP antibody is becoming more relevant. We can see it increasing now you've got symptoms.

Ladies and gents, we've just got time for one more question.

But the doctors will be here for the morning tea break, and you can introduce

yourselves to them and pick their brains. Thank you.

My question is about a steroid injection in the knee.

I've always been quite comfortable with hip, bursitis, shoulders,

but I go back to lecture after lecture when I was a young doctor where we were

told do not inject knees because of the risk of infection.

So I haven't ordered a steroid injection for a knee and I would like to know

when would I for pain, osteo or arthritis.

Sorry, I'd say the risk statistically is probably about one in 400.

So it is quite rare. It's definitely less risky than surgery.

So I think... When would you offer it to a patient? At what point?

So I think once they've exhausted the simple analgesics and before opiates,

I think it's safer than opiates as well. That's my opinion.

But I think if they've exhausted weight loss.

Low-impact exercise and panadol osteo and regular anti-inflammatory,

at that point, I think safer than all the other next-line options is a corticosteroid injection.

And often steroid injections do or don't work.

Is there any way of predicting the patient who might benefit better than another.

If you are, so there is some data suggesting that if you've got synovitis that's

present even in Norway, that you will do better from a steroid injection.

Doesn't mean they will, but they can often do better. And in the setting of

rheumatoid or lupus or those sort of things where you might have or psoriatic

arthritis and you might have an inflamed joint, steroid injection is actually really good.

And so you can do it in that situation quite comfortably and say,

I'm trying to avoid doing other stronger agents for you, particularly in psoriatic

arthritis, where you can go into remission.

And so you don't always need treatment for psoriatic arthritis because you can

have episodic disease. So I'm giving you this steroid injection to avoid something else.

And if you've got cyanovitis here and you've got OA, and I'm going to give you

an injection to try and do it, but the guys were presented that it gets less and less effective.

And so you might do it again and say, oh, it didn't work now.

Now we need to think of our other agents, but we got some time out of and the

data around repeated injections resulting in further OA is important to remember.

But these people are getting worse and need some help.

Nothing is risk-free. And so we've got to get people going.

They can't hear. We're always scared. Can I just add, just for your,

with cortisone injections, if the knee has a boggy swelling,

I think that's a good sign that it's sinovidic.

And a lot of GPs order an MRI straight away and often on the MRI report there'll

be a suggestion that the knee is synovitic and if it's synovitic cortisone injection

is not that bad it's a good idea for short term pain relief but it's not going to be a cure,

I probably wouldn't put one every six, I mean I'd limit it to one or two a year, perhaps three.

I don't know that there's a number about the total number of injections.

I know in the shoulder, the more injections you put in a shoulder,

the risk of developing a complication there is higher.

So if you correlate that to a knee, I'd say maybe limit it to one or two a year.