6th World Congress on Controversies, Debates and Consensus on Bone, Joint and Muscle Diseases

There was much hope when this congress was finally held in an Asian country, particularly in South East Asia. The title was enticing to those who have been practicing rheumatology in this part of the world. The challenges are so different compared to those countries who previously hosted this event.

There was much anticipation that finally issues so pertinent to this part of the world will finally be brought to the fore and debated. I have to say that the event was a total letdown. Don’t get me wrong, the speakers were great but the way the congress was arranged mirrored events that may not be pertinent or relevant to this South East Asia.

There was hardly any focus on Lupus. There was hardly any focus on tuberculosis and the risks it poses in a TB endemic zone. There was hardly any focus on the health economics of biologic therapy, a treatment modality that remains out of reach of the majority of patients in South East Asia.

In short, there was hardly any focus on issues that matter to South East Asia, so ironic when the organizers decided to have it in sunny Bangkok.

A large Chinese delegation which showed up on the first day never returned, perhaps seeing little benefits.

Controversies were not addressed, debates were absent and likely a consensus that this event will not be a priority in the near future.


At #eular2018 in Amsterdam

An annual pilgrimage for many rheumatologists. This time at a beautiful and environmentally friendly city of Amsterdam. The lighting up of the twittersphere with the hashtag #eular2018 is palpable giving many insights into the sessions and thoughts of the participants here.

Managed to only scheme the surface physically but the digital space has allowed a much broader perspective of the goings on. There was reportedly more than 15,000 participants from all corners of the world.

Follow us on twitter or Facebook @rheumatologymy.

Risk of intestinal perforation with tocilizumab

Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs

A Strangfeld, A Richter, B Siegmund, P Herzer, K Rockwitz, W Demary, M Aringer, Y Meißner, A Zink, J Listing
Annals of the Rheumatic Diseases 2016 July 12

OBJECTIVE: To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ).

METHODS: In 13 310 patients with RA observed in the German biologics register Rheumatoid Arthritis: Observation of Biologic Therapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure.

RESULTS: 37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2-0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment.

CONCLUSIONS: The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation.

In plain language……

This study highlights the risk of intestinal perforation for those patients on tocilizumab. Your risk of gut perforation is increased 4-fold as compared to conventional synthetic DMARDs (e.g. Methotrexate or sulfasalazine). Interestingly, some may not present with abdominal pain at all and may not even have elevated inflammatory  markers. So being vigilant about this potential complication, albeit only a small number i.e. 2.7 per 1000 patient years, is wise.