Rheumination

The Kids Are Okay

  As both of my regular readers know, after many years of practice in a community hospital, we have within the last year become semi-academic with the arrival of residents and clinical clerks on our service.  There was a near twenty year period without the presence of these keen clean slates and I must admit, I wasn't sure what to expect. The medical students have been by far the biggest surprise. 

I was a little put off by the new dress code.  In the old days jeans were generally relegated to the ER where they went well with surgical greens and ER personalities.  I was taken aback when I discovered that they couldn't handle a microscope only to find that they had done virtually no histology and little anatomy.  I was flabbergasted when I saw them demonstrating the physical exam from the wrong side of the patient's bed. (more on this another time).  But what is most obvious and which  has truly shocked me the most, is how damn good they are.  

I don't know if it's the newer problem-oriented approach or simply getting the students into the hospital earlier, but the students I've had so far have been amazingly at ease with patients and the whole hospital routine.  The first student we had functioned at what I would consider to be an intern's level.  Within a week I was sending him off to see his own consults and when we rounded I would find a thorough history and physical and even a proposed diagnostic or treatment approach.  Between rounding the student would see patients and write follow-up notes in the charts with confidence.  At first I thought it was simply an outstanding student, and in fact he was, but his classmates have all exceeded my expectations.  They all seem to be at ease with both patient and physician interaction, or at least a lot more comfortable than I was at this stage.

I imagine it's hard for medical school administrators to see the gradual impact of their longterm decisions on curriculum and clinical skills training, but from my vantage point as a  Rip van Winkle of academic medicine, things have changed dramatically, and for the better.

Belimumab and RA

In December I wrote a post about a promising treatment for SLE, belimumab (Benlysta/LymphoStatB).  This drug  decreases the proliferation of B cells by removing the anti-apoptotic effect of BLyS, and Human Genome Sciences has used it to come up with one of the first successful drug trials in SLE.  I was curious though as to why the drug was being tested in SLE when the huge rheumatoid arthritis market beckoned.  After all, rituximab, another anti-B cell biologic has been shown to be successful in this population, and even though the RA market is becoming saturated, it still seems likely that 10% of the RA market would still be more profitable than the entire SLE market.  Well it turns out that the people at Human Genome did think of this but the one smallish study that I did find was not very encouraging.  Of 283 patients, only 35% reached the ACR 20 response, and oddly, higher doses did even less well.  In this day and age, if you're talking ACR 20, you're not in the game.  Most biologics can produce ACR 20 responses of 60% or more, and we quickly move along to check out the ACR 50 and even the ACR70 responses.  

So belimumab seems to work in SLE but not in RA, while the other anti-B cell molecule, rituximab, works in RA but not in SLE. (Actually, most people believe that rituximab works in SLE but are having a heck of a time proving it).  It goes to show how different these two  diseases are and how little we really know about the immune dysfuntion that causes them.

Happy New Year

Okay, my holiday break was a little long, but the blogging business can only compensate for the lousy pay with generous holiday allotment.  And so far 2010 is looking good, rheumatologically speaking.  Not three weeks in and the FDA has given the nod to tocilizumab (Actemra), the latest biological in the anti-RA arsenal.  We now enter the next decade with five ant-TNFs, abatacept, rituximab and tocilizumab.  We'll have to add more seats in the waiting room for all the drug reps, but the more the merrier I say.  Surely one of them will have to break rank and bring down the prices.