Meet Atul Deodhar, MD, MRCP, FACP

Gregg Masters 00:04

Welcome, everyone. I'm Gregg Masters, the producer, co-host of the AMCP Podcast Series Powered by PopHealth Week. Joining me in the virtual studio is lead co-host Fred Goldstein, president of Accountable Health LLC. On today's show, our guest is Atul Deodhar MD Professor of Medicine and Medical Director of Rheumatology clinics in the Division of Arthritis and Rheumatic Diseases at Oregon Health and Science University. Dr. Deodhar is board certified in internal medicine and rheumatology and is a fellow of the American College of Rheumatology and the American College of Physicians. And with that introduction, Fred, over to you.

Fred Goldstein 00:46

Thanks so much, Gregg and Dr. Deodhar welcome to the AMCP Podcast Series Powered by PopHealth Week.

Atul Deodhar 00:51

Thank you very much. Thanks for having me.

Fred Goldstein 00:53

It's really a pleasure to get you on. It's an area we haven't explored much, but obviously this whole area of rheumatology and what we're going to get into over the next two shows is really fascinating. Why don't we start by you giving us an introduction and background to your current work as well.

Atul Deodhar 01:06

So I'm a professor of medicine and I'm the director of the rheumatology clinics at Oregon Health and Science University in Portland, Oregon, and my research interest is psoriatic arthritis and axial spondyloarthritis. And several years ago, about 14, 15 years ago, I started a combined clinic with dermatology for psoriasis and psoriatic arthritis, we call it CEPA Center of Excellence for Psoriasis Psoriatic Arthritis. And it is very important in the field of psoriatic arthritis especially to have a coherent approach for the treatment with dermatologists and rheumatologists predominantly involved. But as we will speak, as I will speak and in our discussion today, there are several other specialists who are required to take care of the patient with psoriatic arthritis. Because psoriatic arthritis patients have problems with metabolic syndrome. They have increased prevalence of diabetes, heart disease, ischemic heart disease, longevity extra, etc. Increased problems with depression. So it's a multi modal approach and our clinic kind of tries to provide that and I have used that in also participating in various research trials on psoriasis psoriatic arthritis. And we'll discuss some of these which were presented recently at the American College of Rheumatology. But that's my background.

Fred Goldstein 02:41

Fantastic. And so I know recently, you were at the American College of Rheumatology, the ACR Convergence 21 conference last fall. What were some of the key issues and important areas discussed there this year?

Atul Deodhar 02:54

Yeah, so American College of Rheumatology Annual Meeting is a huge big meeting, there are about 16 17,000 attendees. This was I'm talking about pre-pandemic times when people would physically attend

this is one of the if not the biggest conference in the world. And about 50% of the attendees are from the U.S. and 50% are in fact from outside of the U.S. And the entire area of Rheumatology is covered. So from inflammatory arthritis like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, they also cover lupus and gout. And they cover osteoarthritis and fibromyalgia. And another interesting aspect of the American College of Rheumatology meeting is it's not just for rheumatologists and doctors. It's for nurse practitioners, physical therapists, occupational therapists, nurse practitioners, etc. And it's an excellent place where you can exchange it's a give and take between various specialties, sorry, between various parts of the rheumatology the various providers within rheumatology. This year was completely the meeting was virtual, I should say last year 2021. The meeting was totally virtual. Because ACR Convergence, virtual meeting and I don't exactly know how many people attended. However, the areas that were covered were again the length and breadth and depth of Rheumatology everything was covered, and my interest being in psoriatic arthritis and axial spondyloarthritis. I attended most of those sessions because I was also presenting. But I did actually look into other interesting areas where this field of rheumatology and new management options is expanding exponentially.

Fred Goldstein 04:51

So what are some of the impacts associated with psoriatic arthritis as we look at that from the U.S. point of view?

Atul Deodhar 04:59

Yeah, good questions. So the prevalence of psoriasis skin condition in the United States is 3%, 3% of the US population has skin psoriasis. And several studies, including the one at my center, has shown that the prevalence of psoriatic arthritis in patients with skin psoriasis is 30%. So if we apply that nationally that will tell you that at least 1% of the US population has psoriatic arthritis. This is a significant inflammatory arthritis, which can lead to structural damage to the joints. As I said earlier, this can affect even longevity of this patient, there is something about this disease that these people have more obesity, diabetes, hypertension, hyperlipidemia and ischemic heart disease and stroke and significant depression. And interestingly, there are various domains that we have discussed that we have discovered, I should say, within rheumatology, even in the musculoskeletal system. The disease affects peripheral joints, it affects enthess, which means where the tendons and ligaments insert into the bone, of course, it affects the skin and the males. And now we are actually concentrating on an area which has been neglected all these years, and that is involvement of the axial skeleton or the spine and we call this axial PSA, axial psoriatic arthritis. This part of psoriatic arthritis has generally been neglected over the years. And most of the studies that have been done clinical trials and patients coming to see us we generally concentrate on their peripheral arthritis, peripheral aches and pains. And they're enthesitis like heel pain and plantar fasciitis etc. There was a lot of interest in the current ACR meeting and I would say in this field in the last year, on the feet, the domain of psoriatic arthritis, which is the axial involvement, axial PSA.

Fred Goldstein 07:01

And when employers and others or payers start looking at this issue, what are some of the key things that they need to sort of consider or that they should be looking at? Obviously, if you're talking about 1% of the population, it's fairly substantial. I would assume given, you know, the various treatment

approaches that it's it's fairly expensive in some cases. So what are some of the points around that in terms of treating this?

Atul Deodhar 07:23

Yeah, the axial, it's interesting because some of the drugs that we use in psoriatic arthritis and almost always the payers would ask us to use the conventional synthetic DMARDs like sulfasalazine, like methotrexate, like leflunomide. And they will say that unless you use this, you're not allowed going to allow you to use biologics. And the biggest problem is, is that these drugs, the conventional synthetic DMARDs, none of them, none of them work on the axial skeleton, methotrexate zero effect on actual skeleton sulfasalazine no effect leflunomide no effects. It is very difficult for a clinician like me to treat my patient with psoriatic arthritis with these drugs, when they have actual skeletal involvement. And interestingly, at the start of the disease and they start their symptoms, maybe only about 5% of the patients have axial involvement, but as the time goes by, it has been shown that over 20 years 70% of the patients with psoriatic arthritis can have involvement of the axial skeleton This is extraordinarily important from population health perspective. And it is very important for the payers to understand that we are not just treating their Oh my knees swollen , well, why don't you give them methotrexate? Yeah, but they also have back pain, they also have actual involvement, and that's a major cause of their pain and fatigue and disability and we need to treat that and several of the drugs. So not just conventional synthetic DMARDs that we are asked to use first there are drugs like Otezla, which is not we have got no effect on the actual skeleton. And then more recently, we actually looking at this that certain country certain diseases rather sorry certain medication, which we thought had no effect on the axial skeleton in ankylosing spondylitis, different disease or axial, sta axial spondyloarthritis different disease. Certain biologics that we thought do not work on the axial skeleton in axial spondyloarthritis interestingly, has shown efficacy in axial PSA, axial psoriatic arthritis. So, to give you an example, ustekinumab is a drug which blocks, IL-12 and IL-23. There is another drug risankizumab blocks purely IL-23. Both these drugs were tried in Ankylosing Spondylitis showed zero effect on the axial skeleton, which was very disappointing. Interestingly, these drugs have shown efficacy in the axial skeleton, and risankizumab hasn't really looked at axial skeleton in psoriatic arthritis but Guselkumab is an example of a pure IL-23 inhibitor, which has shown improvement in the patient's signs and symptoms of involvement of the axial skeleton. And this is an important consideration that as physicians, we must have when we are looking at a patient with psoriatic arthritis as to which domains of the disease are we treating here? What is ailing the patient the most? When the patient comes in says, I got I got psoriasis and I got arthritis. Doc, I got arthritis. When the patient says doc, I got arthritis what they're saying is Doctor I got musculoskeletal pain. And it is our job to see whether it is arthritis which is by definition involvement of the joint or it really is involvement of the tendons insertion and tendinitis and enthesitis and also dactilytis , swollen digit. And also, if you don't ask them oh, by the way, do you also have backache? They will say, Oh, yeah, I also have backache. Yes. Good you ask because they are kind of concerned because their knees swollen. And we are concerned because that is the important joint that you can see and you are going to tap it and drain it and inject it. But if you don't ask about their spinal involvement, you are going to miss it. And that is an important aspect of psoriatic arthritis. And we need to take that into consideration then we treat the patient as a whole.

Gregg Masters 11:32

And if you're just tuning in, you're listening to the AMCP Podcast Series Powered by PopHealth Week, we're discussing key highlights from the American College of Rheumatology Conference the impact of psoriatic arthritis nationally, and implications for both payers and PBMs. With Dr. Atul Deodhar, professor of medicine and medical director of Rheumatology clinics and the Division of Arthritis and Rheumatic Diseases at Oregon Health and Science University. For more information, please visit the AMCP Podcast Series powered by PopHealth week at www.amcp.org/podcast.

Fred Goldstein 12:14

So there's been as you talked about with these newer biologic agents and others that are coming out of using either step therapy or some sort of a prior authorization approach, but it's obviously based on what you're saying extremely important, that the payer or the health plan or the employer that's offering these understand the, to a better level, what the various products do so that they can then allow the physicians to not have to step through all these hoops.

Atul Deodhar 12:42

Exactly right. And we are currently involved and when I say we, it's a combined we of rheumatology, profession, and rheumatology as a community. We are currently involved in developing classification criteria for axial PSA, axial psoriatic arthritis. And using those criteria, we are going to find out what is the prevalence. I told you earlier 3% of US population has psoriasis 1% of the US population, psoriatic arthritis big population health problem, we are now finding out trying to find out what percentage of patients within that 1% have axial involvement, how early it is and we have this idea 5% at an early stage and 70% after 20 years, but we are going to formalize by doing an international study on this. And the second study we are doing is looking at which biologics are actually working on this involvement of this of this domain of psoriatic arthritis. As I said, risankizumab and guselkumab are a couple of drugs that I mentioned. There are other drugs which were shown in this ACR meeting that we are discussing. One is secukinumab which is drug which blocks IL-17 ixekizumab, another drug that blocks IL-17A. Both these drugs have been shown to work on the axial skeleton. That was not that much of a surprise because these drugs also work in axial SPA or axial spondyloarthritis or ankylosing spondylitis. So they working here was not a big surprise. But But yes, it is an important aspect and the payers should understand that the idea of this kind of jumped through the hoops and putting barriers, it bothers the patient its a major barrier for providing good care for this psoriatic arthritis patient.

Fred Goldstein 14:35

Yeah, I know. You know, prior to the show, Dr. Deodhar, I looked up and read an article Direct Healthcare Costs and Comorbidity Burden Among Patients with Psoriatic Arthritis in the United States, published by Merola at all in clinical rheumatology, and I think they showed that the annual direct costs for those with psoriatic arthritis was $26,883 versus the, you know, the control group which didn't have the disease of $7,181. So you're looking at a fairly substantial potential outlay of funds, obviously to treat these individuals.

Atul Deodhar 15:08

Yeah. And what that article, thank you for mentioning that article. What that article did not mention is the other costs, indirect costs, lost work, presenteeism, absenteeism, etc, we can discuss that that's a topic in itself, how these patients go to work and then they, presenteeism is despite being at work, they

don't really have full productivity. So those costs that you're talking about is direct cost because of their health care related thing. But it costs social participation, it costs several things if people are getting disabled, these people are not able to work they have to take time off and axial involvement is also important in that part.

Fred Goldstein 15:46

Absolutely. So let's move to the area of axial spondyloarthritis And what's going on there. ,

Atul Deodhar 15:54

Yeah so axial spondyloarthritis spondyloarthritis This is just for our listeners spondyloarthritis is a family under spondyloarthritis is ankylosing spondylitis, psoriatic arthritis is part of that inflammatory bowel disease-related arthritis is part of that reactive arthritis is part of that. Juvenile spondyloarthritis is part of that from population health point of view. This family is way bigger than rheumatoid arthritis. Every member of this family is as important as rheumatoid arthritis. Rheumatoid arthritis prevalence in this country in the US is 0.6% of the population has rheumatoid arthritis. These data come from Mayo Clinic Rochester, whereas Ankylosing Spondylitis and axial spondyloarthritis which is a bigger piece of the puzzle, which is non radiographic axial, SBA, and ankylosing spondylitis that patients don't really have definitely changes on the sacroiliac joint that itself is 1% psoriatic arthritis is at least 1% reactive arthritis could easily be one percent, IBD associated arthritis could be probably point five or point 4%. We're talking about 3, 4% of the population having spondyloarthritis. One of the diseases under spondyloarthritis in the US, huge problem, a lot of interest in this area, axial SPA or axial spondyloarthritis includes Ankylosing Spondylitis and non radiographic axial SPA. These two conditions the current focus of research has been early aggressive treatment, early aggressive treatment has been accepted to target is accepted in rheumatoid arthritis. We know that if we treat patients with rheumatoid arthritis early and aggressively, we improve their quality of life and we improve or we reduce the radiographic progression. So that is accepted. This concept is somewhat new in this field in this area or in this family of diseases let me call spondyloarthritis. And there is something called minimal disease activity MDA for psoriatic arthritis, and we generally the community of rheumatologist have accepted that our aim of treatment of psoriatic arthritis should be to bring every patient to minimal disease activity. Now your question is about axial, SPA, axial SPA. Early aggressive treatment is very important. And here again, the payers I hope they're listening and in axial SPA, the conventional synthetic DMARDs do not even work. So to ask the doctor to try to methotrexate and sulfasalazine. It shouldn't really be done because it, it has been shown by multiple trials that these drugs don't work. The American College of Rheumatology, along with the Spondylitis Association of America, and the Spondyloarthritis Research and Treatment Network or Spartan, combined have come out with treatment guidelines of 2019 which clearly state that if non steroidal anti inflammatory drugs stopped working, physical therapy stops working. Then the next step in the treatment of actual SPA is strict biologics. There is no intermediate steps of conventional synthetic DMARD. So that's point number one. Point number two, early aggressive treatment in axial, SPA has three distinct advantages. First advantage is that an early aggressive treatment to patients who are in early in their disease, and by early in the disease, I mean, early from the signs and symptoms of development of backache. So, the shorter symptom duration is the important one that we are talking about. If you treat those patients aggressively compared to people who have the disease for 10 years, 20 years, and they haven't had a biologic, you will find that patients who are treated early and aggressively with biologics have much better bang for the buck. You are going to get much better. We are going to push most of the people into remission into low disease activity etc. And at this ACR annual meeting, which we actually did a study on intravenous golimumab. That's just one example.But several other drugs have also shown similar efficacy. But what we showed was if you give the intravenous golimumab IV Simponi Aria, to patients with disease duration of two years or less symptom duration of two years or less, these are patients with active SPA spondyloarthritis versus active SPA in patients who have a disease duration of 20 years, patients who have early disease had much better Disease Control, much better number of patients were pushed into remission low disease activity compared to those similar patients except that they have the disease for 20 years or longer. So that is the first advantage of early aggressive treatment you get better bang for your buck, better symptomatic improvement. Second reason to early aggressive treatment is radiographic progression. Patients with axial SPA unfortunately, some of them are going to get bamboo spine that is the end stage of ankylosing spondylitis, we are trying to avoid that. Early aggressive treatment with TNF inhibitors. And probably also with IL-17 inhibitors reduce radiographic progression. JAK inhibitors is another group of drugs which are coming into this arena. They haven't really shown the efficacy on radiographic progression, but the field is going in that direction. But the important point here is that early aggressive treatment also reduces radiographic progression. If you use it early as opposed to late. There are trials which show that starting TNF inhibitors later, the radiographic progression is higher and they keep on progressing. Starting with early and suppressing the disease, you are able to stop this radiographic progression. And the third very interesting thing that we are finding out and there were several abstracts and presentations at the ACR convergence meeting of 2021 is early aggressive treatment, you are able to withdraw the treatment. When patients come to see us they are, they get depressed when we tell them that oh, yeah, you have got axial SPA? Yeah, we can treat this we can we've got all this good drugs. Patient says, No, but do I have to take this drug for the rest of my life? Nobody wants to have a chronic disease. Nobody wants their doctor to tell them, I'm sorry, you have this disease, you that is going to stay with you for the rest of your life. Nobody wants to listen to that. They want to know whether Can I stop this drug? And can I still stay in remission? What there were several studies, what we are finding out is by this study is you aggressively treat patients open label first. That's the general way these studies are done. This is the study design and describing open label treatment with a biologic for the first six months. And then at the end of six months, those patients who are in remission, you then double blind, you put them into placebo, or active drug. So patient doesn't know afterwards, whether they're receiving placebo, or they're receiving active drug at six months when they are in remission. And in general, what we are finding is between 30% to 50% of the patients remain in remission, without the active drug for another six months. This is drug free remission. This is as close as we come to cure in rheumatology. We don't we're not calling it cure. But it is still an initially these are the early stages of where the research is going. We are kind of mimicking our colleagues from oncology. A woman gets breast cancer gets, you know, radiation therapy, lumpectomy and then chemotherapy. And then they just get off. I mean, their hands off. And now Oh, you're fine. Go and come back after a year to see me. The lady comes back and you said you're still in remission, go back and come back after a year. Is she cured? Well, we hesitate to use the word cure. When I say we know oncologist hesitate to use the word cure, but the lady is in remission from her breast cancer. And that is a great feeling for the patient. In rheumatology, we don't have cure, we are still calling it remission. We don't know how long this remission is going to last but early aggressive treatment. This is another advantage and payers should take note of this. Instead this might be saving them money because you treat them early and aggressively. And have you withdraw the drug and the patient stays in remission. I mean, this is you know, Europe is looking at this EMA is forcing drug companies to do such withdrawal studies. And that's the interesting aspect of this.

Fred Goldstein 24:51

Yeah, it's fascinating, because what you're saying is that early treatment obviously would improve quality of life it sounds like...

Atul Deodhar 24:57

Yes

Fred Goldstein 24:58

...better clinical outcomes and is the possibility to have this, this period of remission in which you're not having to use the drugs?

Atul Deodhar 25:05

Yeah, one one. Yeah. One quick point I wanted to make about the axial SPA is that this condition affects the disease the patients in their youth. Almost all patients with axial SPA, more than 95% of the people, that disease starts before the age of 40, generally in their 20s and 30s. This is a disease of young people where it starts and that is when it affects them the most. And that is the time when they are going to work. This is their work life period. So treating them early aggressively improves the presenteeism, absenteeism that we just touched in the psoriatic arthritis discussion earlier we had if you want to reduce the economic burden of this disease, treating them early and aggressively is very important.

Fred Goldstein 25:52

Fantastic. And thank you so much, Dr. Deodhar for joining us today on the AMCP Podcast Series powered by PopHealth Week.

Atul Deodhar 26:00

Thank you very much for giving me the opportunity.

Fred Goldstein 26:02

And back to you, Gregg.

Gregg Masters 26:03

and thank you Fred that is the last word for today's broadcast. I want to thank Dr. Atul Deodhar professor of medicine and medical director of Rheumatology clinics in the Division of Arthritis and Rheumatic Diseases at Oregon Health and Science University for his time and insights. For more information from the American College of Rheumatologist Convergence 2021 conference, go to www.ACR21.AMCP.AMCPmeetings.org for the AMCP Podcast Series Powered by PopHealth Week, my co-host Fred Goldstein and Dr. Atul Deodhar this is Gregg Masters, encouraging you to follow like and subscribe to the series via www.amcp.org/podcast or the podcast platform of your choice and PopHealth Week streams live on HealthcareNOW Radio.com at 5:30am, 1:30pm and 9:30pm Eastern and 2:30am, 10:30am and 6:30pm Pacific. Bye now.