Rheumination

Darvon, Really?

The FDA has decided after fifty years it's time to get tough with Darvon.  Surprisingly the drug is apparently still popular in the States, if only amongst drug abusers.  Here, I have only a single patient who still uses this mild narcotic.  The patient is in her eighties and has apparently used the drug forever, twice a day.  She lost her family doc recently and so I've had to prescribe her Darvon for her.  I was rather uncomfortable at first, this drug having been out of fashion before I even graduated from med school, so many  years ago. I kind of worried what the pharmacist might think.    I eventually got over the weirdness and now, in fact, I kind of like playing Dr. Marcus Welby  whenever I see her.  

"So, do you think you might need your librium topped up as well?"

A Billion Here, A Billion There...

Last week Johnson and Johnson/Centocor won it's patent law suit against Abbott concerning Humira.  The jury trial concluded that adalimumab (Humira) inpinged on J&J's patent for infliximab, and awarded them 1.7 billion dollars.  Apparently they felt that the fully human antibody was not adequately different from infliximab.  Hard to believe that a jury is left to ponder these kind of decisions.  In any case, Abbott would continue to sell their drug but would owe royalties.  Given that sales of Humira in 2008 were in the order of 4.5 billion dollars, we're talking about serious cash.  Not that Abbott is caving though.  They're appealing the decision and counter suing J&J over Symponi, J&J's own fully human anti-TNF that is just now coming out.  Could be amusing.

Comparative Effectiveness in Rheumatology

Interesting times ahead I think.

  The Obama administration's new Comparative Effectiveness Research initiative seems to have rheumatological biologics in their sites.  That may or may not be a good thing. In one respect this is clearly welcomed.  There are now four anti-TNF drugs available in Canada with a fifth not far away.  Orencia, Rituximab and soon Actemra are the other biologics in the rheumatologist's arsenal. Weirdly, almost every biologic has clinical studies with near identical results for ACR 20, 50 and 70.  Side effect profiles are hard to compare because the important ones, infection and cancer, don't seem to be very high in these studies.  Large databases are starting to tease out some results but not much, and not quickly. Getting to that information isn't so easy either.  Each pharma company brings over the European database researcher that seems to best support their drug, or at least some tiny advantage that they may have tumbled upon.  So it would be nice to have a third party, a party with a little oomph and a little cash,  try to look at all the data and try to sort things out. Head to head trials would be great but I don't think there will be enough cash in the till to do an adequate job with the biologics.

On the down side, and a worry for everybody, is whether the information gleaned will be used to limit choice.  It's a little less a concern here in Canada as in Britain, only because we are already acclimatized to government interference.  In Britain, for example, Orencia will not be covered for RA.  It is in Quebec, but with numerous criteria.  The criteria established are not horribly onerous but the paperwork is.  And it could get worse after the Comparative Effectiveness Research gets rolling.

So there could be some bad with the good, but overall, I think I'm ready for a non-pharmaceutical company based appraisal of the biologics.  

Arava Induced Dextrocardia

When I started my practice many years ago I had to do internal medicine call.  It was good in some respects, keeping my well-earned internal medicine skills sharp, but after a while I had to question the appropriateness of a rheumatologist handling drug overdoses and pre-eclampsia.  I then restricted my call to rheumatology and allergy since we were in the same department, and finally to rheum call alone.  After a decade with little general internal med I can see that I've now become a bit rusty.  Heart sounds are now limited to  present or not present. I pray infections I stumble upon are treatable with the three antibiotics I know, and hope that they are still being manufactured.  Where's chloramphenicol when you need it?  I actually read the computer generated ecg report,  and I completely ignore, so far without any perceptible  negative consequence, all D-dimer results.

But chest x-rays are still just chest x-rays and even I can see that the film in a recent article of Nature Reviews Rheumatology was a bit off.  The article discusses leflunomide induced lung disease but it would appear that it also causes dextrocardia:

The incidence of ILD in the cohort decreased over time, as fewer patients with pre-existing ILD were prescribed the drug following the issue of a safety notice in January 2004. Although not mentioned in the safety notice, the use of a loading dose also declined.

In a separate study, a UK-based group reviewed the clinical characteristics of 32 published cases (including 6 from Japan) of leflunomide-induced pneumonitis in patients with RA. The investigators were prompted to undertake the retrospective review after finding a dearth of information in the literature and clinical guidelines.

Med School Under the Microscope

When I went through first year of med school some twenty five years ago, one of my least favourite courses was histology.  We had a great teacher and great labs, but the problem was that we had so much of it.  Eight months if I'm not mistaken, and many hours a week. I remember thinking that this was way, way too much.  Apparently somebody was listening.

Our service has only recently become  affiliated with a university, and we now have the pleasure of having students and residents on the consult team.  I am only now becoming aware of the new curriculum and training methods.  While demonstrating crystal microscopy lately I gave our student a quick look at a low power field of white cells to orient her before turning to polarised light.  She looked down the tube for several seconds before asking,  "you mean those spots?"  Okay, not the most technical description but I figured we would move on.  It quickly became obvious though that she was very uncomfortable and excused herself because she had not used a microscope since college.  In three years of med school, never a practical histology lab, blood smear or gram stain.

This might be what we refer to as the pendulum swinging a little too far to the other side.  Now I have no idea if this is of any real consequence in modern clinical medicine, apparently greater academic minds than mine think not, but I have to wonder if it is not the cause of a recent problem, at least in Quebec, with a shortage of pathologists.  I have never actually talked to a pathologist about their career choice but I would guess that most were introduced to the field through their first histology and anatomy courses.  It seems now though, that a student can get through his entire med school training without ever seeing tissue, healthy or diseased, close up.  Where will the pathologists come from.  CSI Miami fans?  

Blog On

Took some time off from blogging.  After two years it was good to take a break but I must admit, after a prolonged lay-off, it's hard to get restarted.  It's not that there isn't stuff to talk about, after all, rheumatology changes every day.  And it's fun.  How often can we talk about hockey chants and rheumatology in normal circles?  In fact, when can we ever put pen to paper, so to speak, outside of our daily practice?  

Unfortunately, many of my favourite blogs have fallen be the wayside.  Aspirations of a Joint Doc sputtered shortly after I started.  Pharmalot, Wait Times and now Dr Wes have seemingly packed it, and there are others.  It's fairly predictable, of course, but reading blogs is part of the process and losing all of these seems to take a bit of wind out of the sails.

But there are a few blog worthy happenings afoot.

I've discovered  All Joints Considered, a rheumatology blog by Dr. Oliveira on Medscape, and hopefully that will rekindle the spirit.

Our practice has recently become affiliated with a university hospital and I think the arrival of residents and students will be worthy of discussion.

We'll see.  

OA OA OA OA...OA...OA

Who knew that hockey fans were so rheumatology crazed. Here is one of their favourite chants, the osteoarthritis song. Sounds like a pharma pep rally.

The Perfect Blogging Storm

Been a while since I've posted but I have an excuse.  A few of them.  It's tax time and since my filing system is more primitive than the  shoe box technique, a few nights attention each year is obligatory.  The Montreal Canadiens were in the playoffs.  It's embarrassing to say but that problem was solved in quick order by the Boston Bruins.  As of tonight, I'm a Vancouver Canucks fan.  Most importantly, my computer went nuts.  I'm not computer savvy but I can usually figure out the minor glitches after a while but this time I didn't know where to start.  I could not get either my browser nor mail to get onto the internet, but I-tunes would go to the Apple store without delay.  I couldn't shut down or restart without unplugging.  When I went to the finder to check the applications, the first letter of most, but not every, word was deleted. Now that's just  weird. Eventually I had to re-install everything, but of course, everything did not re-install.  Nevertheless, I'm back,  if not exactly at the best of terms with my digital delinquent.

Got A New Pneumococcus Vaccine Meta-Analysis? Get In Line Please.

As rheumatologists, we specialize in immunosuppression.  Its a knack really.  Unfortunately this preoccupation occasionally leads to some rather serious infections.  Fortunately its rather uncommon, but if we could reduce the incidence further, well all the better.  Vaccination is of course the ideal solution and is in fact recommended by the ACR for all patients taking biologics.That said, there has been debate about the efficacy of the pneumococcus vaccine and this controversy was rekindled by a recent article in the CMAJ. 

There are several controversies  raised by the present CMAJ study.

 

The first should be: Just how many meta-analyses are too many? The study itself suggests that there had been seventeen meta-analysis or systematic reviews prior to this one.  The editorial in the same issue calculates only twelve.  I'm sure there must be several more stewing out there in the statosphere.  Isn't there a law or  at least a code of conduct amongst epidemiologists against this kind of thing. Maybe a mercy rule.  "No answer after ten studies and we call the whole thing off"  Did the granting agencies really think that number eighteen would be just the thing to settle the matter. 

This study argues that previous studies probably shouldn't have used  trial done in 1947.   It also suggests that a study from  the Papua New Guinea highlands is questionable.  Personally, I think that  if we are discussing sixty year old studies we are in serious trouble, and if we are including studies from  the highlands of New Guinea, applying the results to my city dwelling, Starbucks sipping  immunosuppressed RA patients might be a bit of a stretch.  

By the way, the  CMAJ article concludes that the vaccine doesn't work for adults, high risk or not.  The editorial disagrees though, as does the World Health Organization, although neither with any gusto.

If this study has made one thing clearer, it's that another meta-analysis is not going to give us the answer without more data.  Preferably data from the last half-century. 

Rheumatology In Jeopardy

"Okay Alex I'll take  'What are we'  for 2000."

"This -ology is the medical specialty that treats joint, muscle, and connective tissue disorders."

Yes, rheumatology has made it to the big times.  This question was asked on this weeks episode of Jeopardy, with Alex Trebek.  Daniel came up with the answer.

  I suppose it's good news that someone knew the answer, but the fact that it was worth the maximum 2000 points suggests that they didn't expect that to be the case.