Team: LLDAS, aka “Treat to Target 4 SLE”

Base Article: Franklyn K, Lau CS, Navarra SV, et al. Definition and initial validation of a Lupus Low Disease Activity State (LLDAS). Ann Rheum Dis. 2016;75(9):1615-1621. doi:10.1136/annrheumdis-2015-207726

Authors: University of Manchester Fellowship Program

1. Sarah Dyball, MBBS, rheumatology registrar, The University of Manchester
2. Anastasia Madenidou, MBBS, rheumatology registrar, The University of Manchester
3. Mia Rodziewicz, MBBS, rheumatology registrar, The University of Manchester

Team Overview

In lupus, we cheer for LLDAS, oh so grand,
A paradigm shift, that is changing the land!
Practically perfect and so much more
For our patients it opens a door
Low disease activity in rheumatology is not new,
But lupus patients need it, it’s true!

Unacceptable disease burden, patients’ struggles are real,
Morbidity, damage, high disease activity are a big deal
International communities working to get the management strategy right
Treat to target   T2T goal, shining so bright!

You may wonder why so many components, why it took so long?
In SLEDAI, BILAG, SRI4, the steroids don’t belong
Clinical trials have only a 52-week aim,
But with LLDAS, reduced damage and mortality is the lifelong game!

SLEDAI-2k less than four,
Steroids above 7.5mg, is acceptable no more!
Physician assessment less than one, the target is right
LLDAS wins the world cup, on match night

No EMBRACE for belimumab’s trial,
Conflicting evidence won’t make you smile,
Our competitors pit one treatment with another,
But our paper stands out, like no other!

Want to learn more?

See the Q&A on theMednet.org about the following question: What is your approach to practical monitoring of lupus disease activity in clinical practice?

Next report: ARCTIC REWIND

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Team: VITAL, aka the “Simply D best”

Base Article: Hahn J, Cook NR, Alexander EK, et al. Vitamin D and marine omega 3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial. BMJ. 2022;376:e066452. Published 2022 Jan 26. doi:10.1136/bmj-2021-066452

Authors: RheumMadness Leadership Team

1. Eric A. Wilson, MD, second year internal medicine resident at Duke University,
2. Sabahat Usmani, MD, chief internal medicine resident at Weiss Memorial Hospital,
3. Laura Arneson, MD, second year rheumatology fellow at Northwestern University,
4. Meridith Balbach, MD, first year internal medicine resident at Vanderbilt University,
5. Courtney Bair, fourth year medical student at Duke University,
6. Lauren He, MD, first year rheumatology fellow at University of Michigan,
7. John B. Kellogg, MD, first year rheumatology fellow at Duke University,
8. Benjamin D. Lueck, fourth year medical student at Duke University,
9. Michael Macklin, MD, second year rheumatology fellow at University of Chicago,
10. Iman Qaiser, MD, rheumatologist at Choctaw Nation
11. Amanda Rodriguez, DO, second year internal medicine resident at Lankenau Medical Center,
12. Akrithi Updupa Garren, MD, rheumatologist at Medstar Washington Hospital Center,
13. Matthew Sparks, Associate Professor of Medicine at Duke University,
14. Lisa Criscione-Schreiber, Professor of Medicine at Duke University
15. Guy Katz, MD, Physician Investigator and Assistant in Medicine at Massachusetts General Hospital, 
16. David Leverenz, MD, MEd, Assistant Professor of Medicine at Duke University

Team Overview

In this mammoth (25,871 participants) RCT, investigators explore whether vitamin D and/or omega 3 fatty acid supplementation can ward of autoimmune disease. Older adults (men >50 and women >55) were randomized to receive vitamin D (2000 IU daily) plus omega 3 (1 g/day), vitamin D plus placebo, omega 3 plus placebo, or placebo alone. Then, the development of autoimmune diseases (RA, PMR, psoriasis, thyroid, IBD, or “other”) was assessed at 5 years. Those receiving vitamin D had a statistically significant reduction in the 5-year cumulative incidence of autoimmune disease (HR 0.78, 95% CI 0.61-0.99, NNT ~500). In the omega 3 fatty acid arm, there was no statistically significant change (HR 0.85, 95% CI 0.67-1.08).

Albeit an interesting finding, it is far from a slam dunk endorsement for vitamin D to prevent autoimmunity. This trial was limited to older adults; thus, the results are not generalizable to younger patients susceptible to conditions like SLE, scleroderma, etc. Despite the impressive number of enrollees, the cumulative incidence of new autoimmune disease was low (155 cases in the placebo group, 123 in the vitamin D group), resulting in high NNTs.

With so many caveats, why is this study practically perfect? Because it addresses the commonly asked question: “what can I take to stay healthy?” The VITAL study suggests vitamin D might help, particularly in men >50 and women >55, but it also allows us to keep our recommendations realistic. With a NNT of ~500, it’s clear that vitamin D is no panacea.

Want to learn more?

See the Q&A on theMednet.org about the following question: Do you recommend Vitamin D and omega 3 fatty acid supplementation for prevention of autoimmune disease?

Next Report: GCA Score

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Team: COVID Vax Guide, aka the “Buckeye-Vax-Attack”

Base Article: Arnold J, Winthrop K, Emery P. COVID-19 vaccination and antirheumatic therapy. Rheumatology (Oxford). 2021;60(8):3496-3502. doi:10.1093/rheumatology/keab223

Authors: The Ohio State Rheumatology Fellowship Program

1. Cristina Hurley, MD, second year rheumatology fellow, Ohio State University 
2. Megha Kotha, MBBS, first year rheumatology fellow, Ohio State University 
3. Jasmine Thai, MD, second year rheumatology fellow, Ohio State University 

Team Overview

You know what they say, you miss all the shots you don’t take. Vaccines are no Hail Mary buzzer beater from half court.  They’re the layup you practice all day long in the office and patient messaging.  As Arnold et al describe, this is a “pragmatic strategy” to make your life easier.  Corticosteroids, methotrexate, JAKi, rituximab – this team will tell you when to take “the shot” so that it matters in the game. 

This article outlines the humoral responses of patients on common immunosuppressants to influenza, pneumonia, and even shingles vaccinations.  Apply this to COVID19 vaccines and use it for the assist.  Think COVID19 vaccination is a moving target? You’re not wrong. Our visual aid allows you space to update in real time so you can stay in the game.   

Some may think that a primer on detailed plays for ILD, rheumatoid arthritis, PMR, or dermatomyositis might be more important, but we argue that our team has an answer for almost everyone. While weight loss may help you get faster across the court, we’re not sure that’ll end up helping with the score. We’ve got the shot. 

Next Report: VITAL

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Team: ADIRA, aka the “Tendon Ticklers”

Base Article: Vadell AKE, Bärebring L, Hulander E, Gjertsson I, Lindqvist HM, Winkvist A. Anti-inflammatory Diet In Rheumatoid Arthritis (ADIRA)-a randomized, controlled crossover trial indicating effects on disease activity. Am J Clin Nutr. 2020;111(6):1203-1213. doi:10.1093/ajcn/nqaa019

Authors: The Allegheny Health Network Rheumatology Fellowship Program

1. Saloni Goyal, DO, first year rheumatology fellow, Allegheny Health Network
2. Conor O’Donnell, MD, first year rheumatology fellow, Allegheny Health Network
3. Zaina Shahid, MD, second year rheumatology fellow, Allegheny Health Network
4. Sara Shahid, MD, second year rheumatology fellow, Allegheny Health Network
5. Michael Lucke MD, Rheumatologist, Allegheny Health Network

Team Overview

Imagine a team huddle between you and your poorly controlled rheumatoid arthritis patient. You just completed a long discussion to optimize their medications when they throw you a curve ball, “doc what about my diet?”  A setback? I think not! You have your one shining moment when you think back to the ADIRA trial. ADIRA hit a homerun in demonstrating the importance of an anti-inflammatory diet. In this trial, a mediterranean diet with probiotics squared off against a predominantly carnivorous diet and proved to be a heavy hitter in reducing DAS 28 scores. Randomized crossover study design, high compliance to assigned diet due to home deliveries of meals, and stable weights throughout the study minimized confounding throughout the clinical trial.  This remarkable trial has changed clinical practice by putting the ball in the patient’s court, empowering them to seize victory in the clash against rheumatoid arthritis.

Though this study looked at a homogenous Swedish population and the clinical importance of a mildly reduced DAS may not be of great significance to scientific minds, this is of paramount importance to the patient. The patient is finally taken off the bench and steps onto the court to have their Christian Laettner moment to hit a buzzer beater.  Finally, you have created a patient doctor relationship where you can see them hit repeated game winners. When they happily come back to see you, both you and the patient will bask in the glory of victory.

Want to learn more?

See the Q&A on theMednet.org about the following question: How do you counsel patients who ask if there are any dietary modifications they can make to help control their autoimmune disease?

Next report: COVID Vax Guide

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Team: Precision OA, aka the “Bayesian Ballers”

Base Article:  Jiang X, Nelson AE, Cleveland RJ, et al. Precision Medicine Approach to Develop and Internally Validate Optimal Exercise and Weight-Loss Treatments for Overweight and Obese Adults With Knee Osteoarthritis: Data From a Single-Center Randomized Trial. Arthritis Care Res (Hoboken). 2021;73(5):693-701. doi:10.1002/acr.24179

Authors: The University of North Carolina Fellowship Program

1. Natalie Allcott, DO, first year Rheumatology fellow, UNC
2. Pranathi Narayanareddy, MD, first year Rheumatology fellow, UNC
3. Sahar Sawani, MD, first year Rheumatology fellow, UNC

Team Overview

In the storied arena of knee osteoarthritis (OA), precision medicine is a standout rookie, bending norms and ushering in a new era of treatment. Every athlete has their individualized training regimens. Similarly, precision medicine tailors interventions for overweight and obese adults with knee OA, recognizing that a one-size-fits-all approach will no longer score in this dynamic arena.

Researchers used data from the Intensive Diet and Exercise for Arthritis trial, where 343 participants were randomized to diet alone, exercises alone, and diet + exercise cohorts. Outcomes including SF-36 physical component score, weight loss, WOMAC pain/function/stiffness scores, compressive force, and IL-6 were evaluated. Researchers used machine learning models considering factors like genetic makeup, lifestyle, and the severity of knee OA to develop personalized treatment recommendations.

Like a synchronized point guard and small forward, the combined diet and exercise regimen emerged as the powerhouse duo for most participants across outcomes of weight loss since baseline, WOMAC pain, function, and stiffness scores, as well as PCS.  In individuals where the primary goal is to reduce systemic inflammation, diet alone was found to be the choice treatment.

Precision medicine – teamed up with the unstoppable data-crunching skills of machine learning – lays the groundwork for evolving strategies to tackle knee OA in overweight and obese individuals. The individual treatment decisions from precision medicine’s approach are reproducible, data driven, and extendable to other clinical settings. As the shot clock runs down, it’s undeniable – precision medicine can transform the landscape of knee OA treatment by offering individualized care.

Want to learn more?

See the Q&A on theMednet.org about the following question: How do you counsel patients on the benefits of diet and exercise in OA in a way that motivates them to comply?

Next Report: ADIRA

Back to the full list of scouting reports.