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Medicine Matters rheumatology

My name is John Isaacs. I'm professor of rheumatology at Newcastle University. And I also work at Newcastle Upon Tyne Hospitals NHS Trust. I've had the privilege this year of being the chair of the scientific committee of EULAR and therefore have had to have taken over responsibility for the program of the virtual EULAR Congress.

But there are a number of studies on VT at EULAR this year. The two I presented were very highly rated by the scientific committee. And they were highly rated because they were very robust studies. They tell us that being a thromboembolism is an important comorbidity, if you like, for patients with rheumatoid arthritis.

One of these abstracts clearly demonstrated-- and one of the reasons they're robust is because so many patients were involved. So one of them came from the Swedish Rheumatoid Arthritis Quality Registry-- I think that's what it was called-- and looked at almost 50,000 patients with rheumatoid arthritis.

And essentially, it showed that there was an increasing risk of being a thromboembolism as the disease activity increased. So if you compared patients in remission with patients with high disease activity, those with high disease activity had about twice the risk of being a thromboembolism. But actually, there was almost a dose response. So the higher the disease activity, if you use remission as the baseline, as your disease activity gets higher, your risk of being a thromboembolism also gets higher. So that was one of the abstracts.

And the other abstracts came from so-called RABBIT Registry, which is the German Biologics Register. And this looked at almost 10,000 individuals being treated with a variety of drugs. And that showed the patients on biologic drugs. And in particular, anti-TNF drugs had a reduced risk of thromboembolism compared with patients on conventional synthetic drugs such as methotrexate.

I think the reason that the anti-TNF category stood out was simply because there were more patients taking anti-TNF. If you look at the other biologic drugs and group them together, there was an almost statistically significant effect there, but that simply with fewer patients. There were half as many patients taking the other biologics as there were with anti-TNF. And so the confidence intervals overlapped with unity.

But I suspect that any of the biologics or several of the biologics would have had a similar effect, had the study been large enough. So that tells that biologic drugs reduce the risk of thromboembolism.

The importance of this study-- I think the fact that our patients are at risk of thromboembolism is not new. I mean, that's been published some time ago. And the risk of thromboembolism is at least three times as high in a patient with rheumatoid as it is in a healthy individual. controlled for other factors, it may even be a little bit higher.

I think the association with disease activity, again, is perhaps not surprising. But it's not being shown so convincingly before. And I think the biologic story simply tells us that our patients' inflammation is a risk factor for being a thromboembolism. And the biologic drugs are particularly good at suppressing inflammation.

I don't think we should take away the message that methotrexate isn't a good drug. Because it is a good drug. And we will continue to use it as our so-called anchor drug. But clearly, in this study, patients that went on to anti-TNF, their risk was reduced further.

So it's something that we need to be aware of and our patients need to be aware of. We've known for many years, for example, that our patients are at higher risk of heart attacks and strokes. And we, therefore, make sure that their blood pressure is well-controlled, their lipids are well-controlled.

I think the messages from this study are similar. There are other risk factors for venous thromboembolism. Obesity is one. Reduced activity is another.

So in many ways, this reinforces the need for our to adopt to a healthy lifestyle as best they can. Obviously, patients with rheumatic diseases, not the least rheumatoid, do have limitations. And that goes without saying.

But this means, A, it's down to us as their rheumatologists to make sure their disease is absolutely as well controlled as it could be. In other words, the disease activity is as low as it can be, ideally in remission. And if we can achieve that for our patients, then they also need to be doing everything they can in terms of maintaining a healthy lifestyle, a healthy diet, trying to obtain an ideal weight and exercising as best they can, just as examples.

A very topical area at the moment, of course, is COVID infection. And we know that COVID infection increases the risk of venous thromboembolism. And that's for two reasons, partly because of the inflammation associated with COVID, but also because the virus infects the lining of the blood vessels' so-called endothelium. And that itself makes the blood vessels sticky. There's probably other reasons as well.

So in terms of research, you can immediately imagine that people are going to be looking at the risk of venous thromboembolism in patients with rheumatic disease who get COVID infection. Is there a multiplicative effect in those individuals, for example.

So that's one of the nice things about scientific research. There's always more questions to be answered with every finding that's discovered.