New research and recommendations were presented at ACR 2019, The American College of Rheumatology’s Annual Meeting, from November 8-13 in Atlanta. The features below highlight key presentations from the conference.


Intestinal Microbiota & Rheumatoid Arthritis Progression

Animal studies suggest that intestinal microbiota changes prior to the onset of visible inflammatory arthritis. To clarify such changes in patients at high risk for rheumatoid arthritis (RA), with the aim to identify bacteria biomarkers association with RA progression, researchers sequences and analyzed the 16S ribosomal RNA of fecal samples from patients with RA, high-risk individuals, and health controls. The intestinal communities of high-risk patients had a lower diversity than those of healthy controls upon alpha diversity analysis. Beta diversity using principal coordinate analysis showed that intestinal microbiota was significantly different between the groups. Microbiota communities dynamically shifted from controls to high-risk patients to patients with RA, with 35 of 437 species found only in high-risk and RA patients. The study authors state that identifying “the specific microbes [that] characterize individuals at [the] preclinical stage would provide a useful tool for early detection and intervention of RA.”



Treatment Patterns & Healthcare Costs in Newly Diagnosed Psoriatic Arthritis Patients by Physician Specialty

Although differences in clinical practice between the various physician specialties that care for patients with psoriatic arthritis (PsA) may have lasting consequences on patient outcomes, real-world evidence on this topic is lacking. To describe treatment patterns and healthcare costs among patients with PsA stratified by their treating clinician’s specialty, study investigators analyzed the administrative claims of adults with newly diagnosed PsA. Among rheumatologists’ patients, 65% had early pharmacologic treatment, compared with 46% of dermatologists’ patients. Among patients on a medication, roughly 55% were prescribed by a rheumatologist, 8% by a dermatologist, less than 1% by a combination of both, 13% by a primary care practitioner, and 24% by others. When compared with other physicians (33% to 48%), dermatologists were far more likely to prescribe a TNFi (73%). While mean total annual prescription and healthcare expenditures varied greatly among the providers, rheumatologists and dermatologists had similar total costs, despite lower prescription costs among rheumatologists.



Trends in Alcohol Use Hospitalizations in Patients With Musculoskeletal Conditions

Although evidence suggests that alcohol abuse, and associated mortality, is an important public health issue, data are lacking on alcohol use disorder-related hospitalizations in patients with common musculoskeletal conditions. For a study, researchers examined rates of such hospitalizations without overdose, detoxification, or rehabilitation services between 1998 and 2014 among patients with gout, rheumatoid arthritis (RA), fibromyalgia, osteoarthritis, and low back pain. Although the incidence of alcohol use disorder-related primary hospitalizations was low in 1998-2000 for the five conditions, it increased for each over the study period. By 2014, rates were two-fold higher among those with gout, osteoarthritis, or low-back pain; two-and-one-half-fold higher for those with RA, and three-fold higher for those with fibromyalgia. Rates per 100K total National Inpatient Sample claims showed similar, but slightly higher, trends. Claims plateaued by 2014 for all conditions but osteoarthritis. “Providers need to counsel their patients with these musculoskeletal conditions regarding the risk and impact of alcohol use, in order to prevent associated morbidity and mortality,” conclude the study authors.


Long-term, High-intensity Strength Training for Knee Osteoarthritis?

With an unsubstantiated belief that long-term, high-intensity strength training in patients with knee osteoarthritis (OA) might exacerbate symptoms, few have studied it in this population. To determine whether such training can improve mechanistic and clinical outcomes when compared with low-intensity strength training and attention control, study investigators randomized adults aged 55 or older with pain and mild to moderate radiographic knee OA to high-intensity strength training (75-90% 1RM), low-intensity strength training (30-40% 1RM), or attention control (healthy living classes) for 18 months. While knee pain and compressive forces were similar among the groups, knee extension and flexion strength were significantly greater in the two strength-training groups. These and other study results “indicate that long-term high-intensity strength training for knee OA patients is a well-tolerated non-pharmacologic intervention that increases knee extensor and flexor strength, significantly improves self-efficacy, and does not exacerbate knee pain or disease progression relative to low-intensity strength training or attention control,” write the study authors. “An attention control with a focus on healthy living and living with OA, however, is just as effective as high- and low-intensity strength training in improving most clinical and mechanistic outcomes.”



Osteoporosis Management Worsening

With the number of Americans at risk of fracture projected to increase 33% by 2030, thanks at least in part to an increasingly aging population, researchers sought to evaluate osteoporosis management in Medicare enrollees. Participants were Medicare fee-for-service members with and average age of 80.5 and closed fragility (or osteoporosis-related) fracture between January 2010 and December 2014. Cohort characteristics were computed yearly to examine secular trends in osteoporosis management. More than half of patients in each yearly cohort had a comorbidity or medication that increased fall risk, with nearly one-half using opioids. Although fall risk increased, osteoporosis diagnosis, screening, and treatment rates at baseline were low and decreased each year throughout the study period: DXA use was 25%, 24%, 23%, 22%, 16%; diagnosis was 7%, 6%, 6%, 5%, 4%; and treatment was 29%, 24%, 20%, 16%, 11%. “Opportunities exist to better identify and treat patients who have an increased risk of fracture,” write the study authors.