2024 PCP #IMPerative Updates in Rheumatology

Welcomed the challenge to give updates in Rheumatology under 10 minutes during the 2024 PCP Annual Convention.

The QR code to the compilation of references didn't work so here's the link https://drive.google.com/drive/folders/1cZUPyvey-lutM3jgslCrq-5oHakbM5Aw?usp=sharing

1. Sidney Erwin T. Manahan, MD, FPCP, FPRA
2024 PCP Annual Convention
7 May 2024
#IMPerative Mini-Plenaries
Updates in
RHEUMATOLOGY

2. Objective
•Discuss milestones, advances, and/or changes in the management of
patients with rheumatic diseases

3. Disclosures
•NONE

4. COVID-19 Increases the Risk of Autoimmune Diseases
4,140,383 Filipinos
Tested Positive for SARS-CoV-2
As of January 8, 2024, DOH Data
2020-2021
Adjusted Hazard Ratio
for Incident AIRD
South Korea 1.25 (95% CI 1.18 - 1.31)
Japan 1.79 (95% CI 1.77 - 1.82)
Min SK, Hayeon L, Seung WL, et al. Long Term Autoimmune Inflammatory Rheumatic Outcomes of
COVID-19: A Binationalal Cohort Study. Ann Int Med 2024; 177 (3): 291-302. DOI: 10.7326/ M23-1831

5. Differential Risk for Developing Inflam Arth & CTDs
Min SK, Hayeon L, Seung WL, et al. Long Term Autoimmune Inflammatory Rheumatic Outcomes of
COVID-19: A Binationalal Cohort Study. Ann Int Med 2024; 177 (3): 291-302. DOI: 10.7326/ M23-1831
Hazard Ratio
(95% CI)
South Korea Japan
Inflammatory
Arthritis
0.90
(0.65 - 1.24)
2.02
(1.96 - 2.07)
Connective
Tissue
Diseases
1.26
(1.19 - 1.33)
1.78
(1.75 - 1.81)
Hazard Ratio
(95% CI)
South Korea Japan
< 6 mo
1.26
(1.13 - 1.40)
1.87
(1.84 - 1.90)
6-12 mo
1.23
(1.06 - 1.41)
1.67
(1.62 - 1.72)
>12 mo
0.94
(0.40 - 2.21)
1.57
(1.50 - 1.64)

6. COVID-19 Vaccination reduced the risks for AID
Min SK, Hayeon L, Seung WL, et al. Long Term Autoimmune Inflammatory Rheumatic Outcomes of
COVID-19: A Binationalal Cohort Study. Ann Int Med 2024; 177 (3): 291-302. DOI: 10.7326/ M23-1831
No. of Vaccine Doses Hazard Ratio (95% CI)
1 0.59 (0.49 - 0.71)
> 2 0.42 (0.34 - 0.52)
Type of SARS-CoV-2
Vaccine
Hazard Ratio (95% CI)
mRNA 0.43 (0.35 - 0.53)
Viral Vector 0.58 (0.48 - 0.70)
mRNA and Viral Vector 0.44 (0.22 - 0.89)

7. Bedside Reading: Rheum Classification Criteria
2020 - 2024 2015 - 2019 Pre 2015
•Anti-Phospolipid
Syndrome (2023)
•Calcium Pyrophosphate
Deposition Disease
(2023)
•ANCA-associated and
large vessel vasculitides
(2022)
•IgG4 Related Diseases
(2019)
•Systemic Lupus
Erythematosus (2019)
•Inflammatory
Myopathies (2017)
•Gout (2016)
•Sjogren’s Syndrome
(2016)
•Psoriatic Arthritis
(2016)
•Systemic Sclerosis
(2013)
•Rheumatoid arthritis
(2010)
•Spondyloarthritis
(2010-2011)
•Fibromyalgia (2010)
•Osteoarthritis
(1986-1991)

8. Different Features, Different Weights
Domain Criteria Weight
Macrovascular
(Venous
Thromboembolism)
VTE w/ high risk VTE profile 1
VTE w/o high risk VTE profile 3
Macrovascular
(Arterial Thrombosis)
AT w/ high risk CVD profile 2
AT w/o high risk CVD profile 4
Obstetric Morbidity
> 3 consecutive deaths <16 weeks AOG 1
Fetal death 16-34 weeks AOG without PEC
or PI with severe features
1
PEC or PI with severe features 3
PEC and PI with severe features 4
Barbhaiya M, Zuiky S, Naden R, et al. The 2023 ACR/ EULAR APS Classfication Criteria. Arth Rheum 2023 75 (10): 1687-1702.

9. Common Features, Different Scores
CLINICAL FEATURES GPA EGPA MPA
Nasal Involvement +3 +3 -3
Positive for cANCA or PR3-ANCA +5 -3 -1
Positive for pANCA or MPO-ANCA -1 +6
Blood eosinophil count > 1 x 10
9/L -4 +5 -4
Robson JC, Grayson PC, Ponte C, et al. 2022 ACR/ EULAR Classification Criteria for GPA. Arth Rheum 2022; 74 (3): 393-399.
Grayson PC, Ponte C, Suppiah R, et al. 2022 ACR/ EULAR Classification Criteria for EGPA. Arth Rheum 2022; 74 (3): 386-392.
Suppiah R, Robson JC, Grayson PC, et al. 2022 ACR/ EULAR Classification Criteria for MPA. Arth Rheum 2022; 74 (3): 400-406.

10. Bedside Reading 2: Rheum Guidelines
Gout 2020 ACR 2021 APLAR
Osteoarthritis 2023 EULAR, 2019 ACR, 2019 ESCEO
Rheum Arthritis 2022 EULAR, 2021 ACR 2018 APLAR
Spondyloarthritis 2019 ACR/ SAA/ SPARTAN 2018 APLAR
SLE 2023 EULAR 2021 APLAR
Lupus Nephritis 2020 EULAR/ ERA/ EDTA, 2024 KDIGO
AAVs 2022 EULAR, 2021 ACR/ VF, 2024 KDIGO

11. Increasing Concern for Glucocorticoids Adverse Events
Standard Dose Moderate Dose Reduced Dose
Pulse Steroids Nil OR 0.25 - 0.5 g/d x 3d0.25 - 0.5 g/d x 3 days0.25 - 0.5 g/d x 3 days
Week 0 - 2 0.8 - 1 mkd (max 80 mg)0.6 - 0.7 mkd (max 50 mg)0.5 - 0.6 mkd (max 40 mg)
Week 3 - 4 0.6 - 0.7. mkd 0.5 - 0.6 mkd 0.3 - 0.4 mkd
Week 5 - 6 30 mg 20 mg 15 mg
Week 7 - 8 25 mg 15 mg 10 mg
Week 9 - 10 20 mg 12.5 mg 7.5 mg
Week 11 - 12 15 mg 10 mg 5 mg
Week 13 - 14 12.5 mg 7.5 mg 2.5 mg
Week 15 - 16 10 mg 7.5 mg 2.5 mg
Week 17 - 18 7.5 mg 5 mg 2.5 mg
Week 19 - 20 7.5 mg 5 mg 2.5 mg
Week 21 - 24 5 mg < 5 mg 2.5 mg
Week 25 onwards < 5 mg < 5 mg < 2.5 mg
KDIGO Lupus Nephritis Working Group. KDIGO 2024 Clinical Practice Guidelines for the Management of Lupus Nephritis.
Kidney Int 2024; 105 (1S): S1-S69. DOI: 10.1016/j.kint.2023.09.002.
Glucocorticoids in Acute Gout
Prednisone 30-35 mg/day for 3-5 days

12. Beyond Diagnosis and Treatment
•Addressing Reproductive Health Among Patients with RMDs
Sammaritano LR, Bermas BL, Chakravarty EE, et al. Arth Rheum 2020; 72 (4): 529-556. DOI: 10.1002/
art.41191
•Supporting RMD patients in healthy and sustainable paid work
Boonen A, Webers C, Butink M, et al. Ann Rheum Dis 2023; 82: 57-64. DOI: 10.1136/
annrheumdis-2022-222678
•Preventing RMD progression via lifestyle and work participation
Gwinnutt JM, Wieczorek M, Balanescu A, et al. Ann Rheum Dis 2023; 82: 48-56. DOI: 10.1136/
annrheumdis-2021-222020
•Vaccinations
Furer V, Rondaan C, Heijstek MW, et al. Ann Rheum Dis 2020; 79: 39-52. DOI: 10.1136/
annrheumdis-2019-215882.

13. Screening for MSK Disorders?
Go to https://phex.ph

14. Anatomy of an ANA Result
Positive ANAat 1:320Homogeneousby HEp-2 IIF
TEST RESULT TITER PATTERN METHODOLOGY
Clinical
Relevance
Likelihood
of AID
Guide to subsequent
autoantibody testing
Clue to specific SARD
Clues to test accuracy
Trivia: Most competent labs detect antibodies
against NUCLEAR, CYTOPLASMIC, and MITOTIC
components.

15. Nuclear ANA Patterns and their Relevance
Standardization of HEp-2 ANA Reporting through ICAP (anapatterns.org)
HOMOGENEOUS
SPECKLED
CENTROMERE
DISCRETE DOTS
NUCLEOLAR
PERIPHERAL/ RIM
PLEOMORPHIC
AC-1
AC-2AC-4AC-5
AC-3
AC-6AC-7
AC-8AC-9AC-10
AC-11 AC-12
AC-13 AC-14
AC-29
Not associated
with any SARD
Highly specific
for SLE
Neoplasms,
GVHD, Crohn’s

16. Summary
•COVID-19 infection and vaccination affects
autoimmune disease incidence
•Rheum classification criteria are weighted
•Recent rheum CPGs improve on the use of
newer and novel treatment agents
•Change in the use of GC in the rheumatic
diseases
•A positive ANA doesn’t always indicated
the presence of autoimmune diseases