15 November 2023
A few of my favourite things: Professor Rebecca Grainger
The American College of Rheumatology Convergence is in full swing, and we’re joined by New Zealand rheumatologist Professor Rebecca Grainger to discuss the highlights of the day.
The biggest take-aways for the University of Otago lecturer were on the exciting future of CAR T-cell therapy, the more immediate need for ultrasound training and the seemingly persistent threat of gout to cardiovascular health.
My morning started off with a really inspiring session on CAR T-cell therapy, where we heard from Michael Sadelain, an oncologist in the United States who basically pioneered the use of CAR T-cells in haematological malignancy.
Then Georg Schett, who spearheaded this in lupus patients in Germany, spoke about a basket trial where he’s treated 15 patients with lupus, inflammatory idiopathic myositis and systemic sclerosis – and they’re all doing well.
The final speaker spoke about a different type of CAR T-cell construct that’s going to target T cells, and had a preliminary mouse model eliminating or preventing the development of multiple sclerosis.
It’s almost like hearing about TNF inhibitors 25 or 30 years ago – it just feels like we’re on the cusp of something really big. The challenge is ‘when’, ‘who’ and the cost, but it’s certainly a very exciting new therapeutic on the horizon.
If I had a patient who had really severe lupus who’d had every conceivable therapy we had available, I might start phoning a friend to find out when the next CAR T-cell trial in Australia would be. I don’t think it will be too long before someone will bring it in as something like a rescue therapy.
Another fascinating and much more practical session was on giant cell arteritis and rapid access clinics. What was so interesting was hearing about how ultrasound imaging is changing the way we approach and can diagnose giant cell arteritis.
Wolfgang Schmidt synthesised the data and presented a compelling case for rapid access clinics improving patient outcomes and really argued that they’re a standard of care, reducing blindness in at least three sites. But it requires a change in the availability of services so that you’ve got an ultrasonographer or a rheumatologist who can ultrasound.
I spoke to him afterwards about the practicalities, and ultrasound training has been part of rheumatology training in Germany for 25 years and, in 2022, a core competency for rheumatology registrars will be ultrasound for the diagnosis of giant cell arteritis.
Interestingly, a previous plenary mentioned how Canadians have developed a curriculum for ultrasound training in Canada, which was data-driven and included expert consensus. And Wolfgang said that now in the US, programs compete by offering ultrasound as part of their training.
So New Zealand and Australia, which have no requirement for ultrasound training to become a rheumatologist, are beginning to be an outlier. We’re getting close to the time that we’ll have to proactively consider what is the minimum in formal and informal training in ultrasonography and, more importantly, what our services are doing about providing this important diagnostic tool.
Then we had the plenary, which was an outstanding mix of very clinically focused and basic science information.
One highlight was a really nice administrative data study on ANCA-associated vasculitis and pregnancies, which confirmed women with AAV have higher risk of preeclampsia and a three-fold increased risk of preterm birth. That’s important because this disease does happen in people of childbearing age.
Another great presentation looked at the risk of major adverse cardiovascular events with glucocorticoid use in an elegant study of Veterans Affairs data, which showed about an average 4% increased risk of major adverse cardiovascular event with glucocorticoid use.
But they quantified the risks, showing that 5mg for 30 days led to a 5% increased risk, and 5mg for 90 days led to a 10% increased risk.
And interestingly, there was still an increased risk if the glucocorticoid had been stopped a year before the event.
So, the takeaway from that is it’s time to acknowledge that this is a drug where, even if we’re managing osteoporosis and hypertension, there’s still a significant increased risk of cardiovascular events.
There’s no doubt that there’s a role for glucocorticoids. They’re life changing when used correctly.
But this research emphasises the need to use them at the right time and the right dose and get people off them or have the informed conversation about them. Perhaps this is thinking about the patient in front of you and their individualised cardiovascular risk.
And while we’re talking about cardiovascular risk, the other big administrative dataset presented at in the plenary today was on cardiovascular risk and gout.
Boston’s Hyon Choi group showed even when they controlled for cardiovascular risk factors, there was still an elevated risk of cardiovascular death and gout which hasn’t changed over two cohorts, 20 years apart.
They’re hypothesising that gout itself is the cardiovascular risk, and proposed possibly using continuous low dose colchicine.
This is a common disease and cardiovascular disease remains a major cause of morbidity and mortality, so it’s not over for the cardiovascular-gout stories.
Lastly, I just wanted to highlight how fun it has been being back in a room with all our international colleagues, and that I hope we see more Australians and New Zealanders wanting to come again. It’s been marvellous and there’s just so much new and interesting data coming out.