Emerging Research from Days 1, 2 & 3 of the ACR Convergence

The 2021 American College of Rheumatology (ACR) Convergence kicked off with a diverse selection of sessions and posters exploring the latest research in the field. Below are some of the updates from days 1, 2, and 3 of the conference.

Opening Session

Kicking off the 2021 conference was Dr. David Karp, the President of ACR who noted that a central focus of this year’s conference was to address critical cross-country themes, such as equity, access to care, COVID-19, and more. And the Opening Session wasted no time diving into those themes by starting with a presentation given by Dr. Ayoade Alakija, Co-Chair of the African Union Vaccine Delivery Alliance.

Dr. Alakija spoke about the critical issue of health equity that has been brought into the limelight by the COVID-19 pandemic by noting the stark differences in the availability of diagnostic and therapeutic tools in high- versus low-income countries.

In Africa, for instance, only one in 20 have been tested for COVID-19, and the African Union has received 5 percent of the vaccines ordered. In the U.S., however, there are about two tests available for every person, and North America, Europe, and Israel have all been given more booster shots than the amount of initial shots received in the 18 African countries.

After reviewing the global health inequity seen throughout the COVID-19 pandemic, Dr. Alakija then drew a parallel to the specialty of rheumatology as a whole since rheumatologists often deal with diseases that have similar statistics to COVID-19 in countries like Africa. In fact, most people in Africa who are suffering from rheumatic diseases have no idea because there are very few diagnostics and a lack of awareness of rheumatology as a specialty.

Due to these global disparities, Dr. Alakija stressed the importance of finding a way forward for health equity—not just during the COVID-19 pandemic, but overall—and encouraged attending rheumatologists to forge new networks so that previously unheard voices can be included in the global conversation.

Engaging the Full Rheumatology Care Team to Improve Patient Care & Outcomes

The session titled “Engaging the Full Rheumatology Care Team to Improve Patient Care and Outcomes” featured an international panel focusing on how nurses, patients, clinicians, and other members of the multidisciplinary team can work together to enhance care delivery. Here’s a quick recap of each presentation.

Building Capacity for Pediatric Rheumatology Nursing in South Africa

First up was Dr. Chris Scott from the University of Cape Town. To highlight the heavy burden of rheumatic diseases on low- to middle-income countries, Dr. Scott noted that out of the 6 to 7 million children with juvenile idiopathic arthritis (JIA), 78 percent live in Africa and Asia. But since there’s a lack of awareness and diagnostics in these countries, only a small fraction of children with JIA are treated.

Dr. Scott argued, however, that nurses can play an important role here since the majority of patients in Africa are seen by nurses first.

He then noted that different modalities of teaching, such as online training, can help educate nurses, and other solutions include programs like the African Pediatric Fellowship Program, which has trained at least 175 physicians and nurses on rheumatic and musculoskeletal diseases (RMDs) in children.

Empowering Patients in Rheumatology Research & Care Delivery

Next was Ms. Emily Sirotich from McMaster University. Ms. Sirotich works as a patient engagement lead in the COVID-19 Global Rheumatology Alliance, which aims to collect, analyze, and disseminate information to help improve patient care.

By engaging patients in the form of shared leadership—meaning rheumatology patients are involved in the research design and decisions—the COVID-19 Global Rheumatology Alliance has been able to address, participate in, and create sustainable equity and inclusion initiatives.

And when it comes to bridging the gap between research and care, Ms. Sirotich discussed the following considerations:

• Patients as research partners, meaning patients drive research questions and have the ability to access, collect, and own health data
• Dissemination of knowledge to patients in the form of easy-to-understand language and graphics
• Shared decision-making by providing a safe place for patients to ask questions while simultaneously considering any barriers they may face

To conclude, Dr. Sirotich argued that patient empowerment is actionable, achievable, and beneficial to both providers and patients.

Developing & Using Functional Outcomes Assessments in Patients with RMDs in a Team Setting

The third presentation was given by physical therapist Dr. Helene Alexanderson from the Karolinska Institutet in Sweden, whose research and clinical practice both focus on idiopathic inflammatory myopathies. Since these conditions can have a variety of impacts, including arthritis, muscle impairment, and myocarditis, it’s important to use assessment tools like the FI-2.

FI-2 involves a series of seven tasks like shoulder flexion, neck flexion, step test, and heel lifts to measure a patient’s impairment. When it came to its development, it was validated in a team setting involving physical therapists, rheumatologists, nurses, and patients. The FI-2 was then implemented in all rheumatology centers in Sweden, and a shorter version called FI-3 was also developed with the Mayo Clinic so it could be used on an international level.

Due to the success of these collaborations, Dr. Alexanderson noted that the development and validation of assessment tools in a team setting can enhance the acceptance and implementation of a new tool.

Training Physiotherapists & Occupational Therapists in RMD Rehabilitation to Advance the Care of Patients

Rounding out the session was physical therapist Dr. Anamaria Jones from the Universidade Federal de Sao Paulo in Brazil to talk about RMD Rehabilitation.

RMD Rehabilitation is a part-time, one-year program that’s designed to train physical therapists and occupational therapists to become specialists in rehabilitation for RMDs. It’s the only training program for RMD rehabilitation in Brazil, and more than 150 students have completed the program to date.

Its structure is divided into several parts involving theory, education, outpatient care, and inpatient care among others—all with the goal of improving the assessment and treatment of patients with RMDs.

Together, all four of these presentations stressed the importance of involving all members of a care team to improve the outcomes of patients.

Rheumatology Complications of Emerging Viral Infections

Day 2 of the 2021 American College of Rheumatology (ACR) featured the Basic and Clinical Research Conference, a two-day event exploring the rheumatology complications of emerging viral infections, specifically COVID-19. This conference featured a wide variety of panelists from around the globe investigating the impact of COVID-19 on the field of rheumatology.

Leading the opening session was Dr. Philip Krause, Deputy Director in the Office of Vaccines Research and Review in the FDA’s Center for Biologics Evaluation and Research. Dr. Krause evaluated the role of the rheumatologist in the COVID-19 pandemic.

Given the number of COVID-19 unknowns—including the long-term impact of the COVID-19 vaccines—Dr. Krause urged rheumatologists to learn more about the relationship between COVID-19 rheumatic diseases to help their patients combat COVID-19.

And focusing on vaccines, Dr. Krause shared what the FDA has been doing to improve their evaluation of how to use vaccines to help specialists, such as rheumatologists, better understand their impact on patients with rheumatic diseases, keeping regulatory goals in mind, primarily the need for reliable, rapid decision making in vaccine development and distribution that doesn’t prioritize speed over reliability.

Impact of COVID-19 in Patients with Rheumatologic Conditions

One session from the conference was presented by Dr. Jinoos Yazdany, Chief of the Division of Rheumatology at Zuckerberg San Francisco General Hospital, who shared her perspective on one of the most critical knowledge gaps amid the pandemic—the impact of COVID-19 on patients with rheumatological conditions.

The hazard ratio of the virus in patients with rheumatic autoimmune diseases was higher than most other groups, and these patients have experienced higher rates of COVID-19-related hospitalization and mortality. And according to The Swedish National Patient Register, studies have shown a higher risk of COVID-19 in patients that already have either rheumatoid arthritis or another inflammatory joint disease.

A large part of that is due to the fact that many of these patients regularly receive steroids, immunosuppressants, or other autoimmune medication, which can increase their risk of these complications. And while age and comorbidities play a significant role in these outcomes, emerging data reveals that patients with rheumatic diseases taking these medications have higher rates of in-hospital complications.

Looking back at the whole picture, Dr. Yazdany summed up the risk of COVID-19 in rheumatic diseases, and shared the following:

• COVID-19 outcomes for patients taking immunosuppression for autoimmune diseases are largely driven by older age and comorbidities
• Consistent signal of worse outcomes with a moderate or high dose of glucocorticoids
• Worse outcomes with rituximab, JAKi, SSZ, and several other immunosuppressants (CYC, MMF, AZA, TAC)
• Even with full vaccination those taking anti-CD20 drugs and some immunosuppressants are at risk for severe COVID-19

But Dr. Yazdany urges rheumatologists to avoid stopping these medications altogether. A flare-up in a patient’s rheumatic disease can put them in the hospital, increasing their risk of COVID-19 and COVID-19 complications even further. She recommended talking to your patient and adjusting their care plan accordingly.

To conclude, she noted that while these risks aren’t going away any time soon, there are ways we can work to overcome these obstacles, such as global collaboration to better understand the full scope of COVID-19’s impact on rheumatologic conditions. Most recently, as part of this collaborative effort, she is working to develop a prediction rule to help determine which patients are at risk of negative outcomes from COVID-19, such as respiratory distress syndromes in patients with rheumatic disease.

COVID-19 Vaccine in Immunosuppressed Adults with Autoimmune Diseases

Researchers are getting a detailed look at how the COVID-19 vaccine affects specific segments of the population. While the clinical trials of the mRNA-1273 SARS CoV-2 vaccine did not include subjects with a history of autoimmune disease, a recent comprehensive analysis of the vaccine’s effect on those with rheumatic diseases is shining new light on COVID-19 prevention options for immunosuppressed adults.  

To examine the safety and immunogenicity of the vaccine, 220 participants were carefully selected and closely monitored. This group included 131 patients with rheumatoid arthritis (RA), 23 patients with systemic lupus erythematosus (SLE), 8 patients with other rheumatic diseases, and 58 subjects in the control group. The participants were given a 2-dose regimen of the mRNA-1237 SARS CoV-2 vaccine. Researchers looked for adverse events throughout the 28 days following each dose.

Side effects such as pain at the injection site were common after the second dose for both RA patients and the control group. Swollen joints were reported more frequently in RA patients after each dose, but there was no clear increase in disease activity.

After the first dose, seropositivity was lower in RA patients (67.7 percent) and SLE patients (34.8 percent) compared to the control group (100 percent). After the second dose, seropositivity in RA patients climbed to 88.5 percent and 78.3 percent in SLE patients. Medication such as rituximab lowered the efficacy, but the patient’s age had little impact, as seropositivity was nearly the same in older and younger adults.   

The study illustrated the effectiveness of the COVID-19 vaccine on immunosuppressed RA patients and found no measurable risk of rheumatic disease flare-ups caused by the vaccine.