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ACR 2015: San Francisco Rheuminations



This guest post is by Dr Anne Chung. Anne works in our Chatswood & Parramatta clinics.

I had been looking forward to attending the 2015 American College of Rheumatology (ACR) Annual Meeting in San Francisco for some time and the meeting certainly lived up to my expectations!

The ACR Annual Meeting is one of the two major international rheumatology conferences held each year and it kicked off on the 6 November and wrapped up on the 11 November. More than 16,000 rheumatologists and related health care professionals from all over the world attended to share knowledge and results including updates on the latest research and debate the hottest topics.

This is my third time attending an international conference, but the sheer size of the ACR Annual Meeting continues to amaze me. This year the meeting took place at the Moscone Convention Centre and the exhibits and scientific sessions spanned all three buildings. There were multiple sessions taking place simultaneously, so you have to be selective and plan ahead as to which to attend. Even though the lecture halls were large, for popular sessions… if you don’t get there early…then expect to stand!

To help us plan out our meeting, the ACR designed an excellent app which I found most helpful in assisting me navigate a meeting of this scale.

There were many great talks, some highlights for me were:

  • Hot topics in Osteoarthritis, where data on the use of glucosamine and chondroitin on pain and structure was reviewed. Other hot topics included central pain in osteoarthritis and the importance of behavioural approaches in osteoarthritis, particularly weight loss, physical activity and coping skills.
  • The discussion on Biosimilars in Rheumatology. Biosimilars are a copy of existing biologics developed for the treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis which have undergone extensive analysis and are deemed similar, but are not identical to the original drug. Biosimilars will be cheaper than the original biologic drugs and an alternative option for patients. There is ongoing discussion regarding how it should be incorporated in practice. The talk was a fantastic overview on this complex, evolving area of medicine.
  • The great debate over long term, low dose corticosteroids use in the treatment of rheumatoid arthritis – it comes down to weighting the risks and benefits.
  • Maintenance therapy in ANCA associated vasculitis which focused on challenges in achieving remission and how to predict and prevent relapse with appropriate maintenance therapy.
  • Current state of the art in Spondyloarthritides which touched on the patient’s concerns and perceptions on their disease and linking it back to what is shown in the latest studies.
  • ACR Abstract Sessions I particularly liked the clinical aspects sessions which presented data to show that “treat to target” is an effective management strategy and is closing the mortality gap between patients with Rheumatoid Arthritis and the general population.
  • Another paper presented data which showed that the annual rate of hospitalisation in the United States for gout has overtaken admissions for rheumatoid arthritis, which highlights not only the increasing prevalence of gout and impact of advances in Rheumatoid Arthritis care, but the need to treat gout more aggressively, adopting a “treat to target” approach in lowering serum uric acid levels.
  • Issues in Ultrasound addressed whether it is time to include ultrasound in the response remission criteria for Rheumatoid Arthritis as it is a tool that allows us to better detect synovitis and disease activity more sensitively and thus make better treatment decisions. This was of particular interest to me as I am embarking on an ultrasound course to incorporate ultrasound into my regular clinical practice.

Looking back, the meeting was really quite intensive (particularly when you factor in jet lag) but it provided me the luxury of being in the position to absorb and learn from experts from all over the word. Moreover, it was a great opportunity to catch up with colleagues and mentors and it certainly made me feel a part of the larger rheumatology community.

It was great seeing so many with similar interests, all keen to be updated about the latest in rheumatology. I am already looking forward to my next meeting!

A Current Affair’s Arthritis Exclusive


Arthritis Exclusive ACA

Any press is good press.

I think this is true for arthritis awareness.

We are so starved of media attention, that it’s a remarkable event when arthritis makes prime time.

In the last 2 weeks, I think I’ve had 10 patients come in to ask about the medication highlighted in this A Current Affair piece, Xeljanz.

It’s been approved on our pharmaceutical benefits scheme, meaning that it is now available to those patients who qualify at a very much subsidised price.

While the story is reasonably sensationalist, and it does generate work in trying to explain to patients who do not have rheumatoid arthritis or those who do not meet qualification criteria why it’s not the medication for them, it at least starts a conversation.

What are your thoughts about this sort of media coverage?

Watch Your Back


We suspect that up to 80% of Australians experience back pain at some point in their lives. A number of these become chronic and it’s a huge drain on our health resources.

While this is not hard science, Men’s Health magazine recently surveyed about 400 Australian men between 20-40 years of age about their back pain.

The results are interesting:

Back Pain_The daily grind

It is estimated that about 5% of patients with chronic back pain have inflammatory back pain and in turn, some of those with inflammatory back pain will end up developing Ankylosing Spondylitis, a serious disorder I’ve written a lot about.

Here’s Dr Andrew Rochford, Channel Seven News National Health Editor talking about the Men’s Health Survey and Watch Your Back, an Ankylosing Spondylitis awareness campaign.

Why bother targeting this small group?

Well, the answer is that much can be done for this particular group.

Find out more at http://empowered.org.au/watch-your-back/

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Musings on Sri Lankan Rheumatology

Galle Face Green

Galle Face Green

I was fortunate to be in Colombo on the weekend to talk to the Sri Lankan rheumatology association.

The brief was to share the experience of biologic use for rheumatoid arthritis (RA) in Australia and to give a practical perspective as a clinician in private practice. It was a difficult talk to prepare as we have very different health systems so I hoped to share some thoughts while opening up the floor to discussion.

Sri Lankans are reserved and very polite. As they warmed up, there were thankfully questions and a shared conversation.

Here’s some of what I learned:

Sri Lankan rheumatologists are up to date. Many have trained in Western countries and been exposed to alternative health systems. They speak the same rheumatoid lingo, believing in the window of opportunity and wanting to practice a treat-to-target strategy.

But the situation they work in makes the above very hard.

Access issues abound. Consider that Australia and Sri Lanka have a roughly equivalent population, 20+ million. There are around 22 practising rheumatologists in Sri Lanka vs my guess of 280 practising Australian rheumatologists.

Health is basically government-funded. Private hospitals with clinics do exist but that caters to much smaller numbers. Waiting lists are very long. Clinics are jam-packed with patients who may have travelled hours to then wait a further few hours for a few minutes of the doctor’s time. The rheumatologists are perpetually pushed for time.

Sri Lankan rheumatologists work much harder than yours truly. They have full time jobs (5 and a half days) in a government hospital. Many then leave to work a few hours after their public hospital shift in a private hospital. Most work a full day Saturday.

Cost containment is a major issue. They have full access to conventional DMARDs such as Methotrexate, Sulphasalazine, Hydroxychloroquine and Leflunomide.

Access to biologic medications is understandably restricted in this much poorer country. I audited our own clinic’s use of biologics and we would very likely have more patients on biologic medications than in the whole of Sri Lanka.

I was very surprised to hear that the most used TNF-inhibitors for RA worldwide, Adalimumab and Etanercept, are not available.

Instead they have access to Infliximab, Rituximab and Tocilizumab (compared to the 9 biologic medications we have available in Australia as well as the new targetted-DMARD, Tofacitinib).

One rheumatologist told me that they could also access Golimumab but it is not really used as there is a very clear preference for intravenous medication in Sri Lanka. This seems to be due to the hospital system, the assumed better compliance, and the fact the medications are not used continuously. Instead, biologics are prescribed for short courses due to costs, for eg, 6 months of Tocilizumab only.

With the high rates of tuberculosis, the preference is to use Tocilizumab and Rituximab.

I also learned of the use of “copies” of biologic medication being used. These are termed non-comparable biotherapeutic products. They originate from India and China from what I was told. Unlike biosimilars, they seem to have less robust actual clinical trial data for efficacy and safety. I had not heard the term before so I googled. You can read more here: link.

I always find it fascinating to find out about rheumatology in other countries. Australia is the lucky country, and that’s for both rheumatologists and our patients.

Putting our complaints into perspective is a useful exercise.

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Should rheumatologists worry about Dr rating sites?


My mate, Dr Rob Russo, was asking me about negative comments on doctors made by patients on the web. He was wondering how these could be monitored.

I didn’t know how this could be done and my response was that I personally wouldn’t bother as there was nothing positive to be gained by finding out.

We then talked about doctor rating sites. I did not think these were really in use in Australia but I resolved to find out more.

I found ratemds.com and then searched rheumatologists in my city: https://www.ratemds.com/best-doctors/nsw/sydney/rheumatologist/

There’s only a small handful of my rheumatology colleagues on here and I was glad to see that the only review I had was positive.

(By the way, I didn’t write that review!)

A specific Australian Dr rating site is: http://www.doctoralia.com.au/healthpros/speciality/rheumatologists-1719

I can’t imagine rheumatologist reviews are that useful at the moment.

For one, there are so few of my colleagues that appear on these sites. And even when they appear, there are so few reviews.

I had thought that it would only be aggrieved patients who used these sites to vent but from this small sample, this does not appear to be the case.

One major issue is that the reviews are anonymous (which I can understand being done to protect a reviewer from exposing detail of their medical history). But, this does mean that these sites have less credibility than a site like TripAdvisor.

So, I’m interested to hear if any of you have actually used a Dr rating website? Does it provide useful information? Should we take them seriously?

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