Meet Atul Deodhar, MD, MRCP, FACP @OHSUNews Part 2

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  00:45

Thanks so much, Greg and Dr. Deodhar. Welcome back to the AMCP Podcast Series powered by PopHealth Week. It's great to get you back on the show for an encore appearance for the second discussion of the conference. Why don't you provide just a brief background before we get into some of the additional topics?

Atul Deodhar  01:00

Yeah, thank you, Fred. Thank you for having me again. My name is Atul Deodhar. I'm a professor of medicine and medical director of the rheumatology clinics at Oregon Health and Science University in Portland, Oregon, and my research interests are in the field of psoriatic arthritis and also in axial spondyloarthritis, which is a has got Ankylosing Spondylitis and non radiographic axial spondyloarthritis. I have a special clinic for patients with psoriatic arthritis, combined clinic where a dermatologist and I see patients together. It's, unfortunately, it has become a little bit of virtual, we don't see the patient same at the same time because of this COVID pandemic. But it's a clinic that provides a multidisciplinary care to the patient with psoriatic arthritis. But that's my background, and I'm happy to expand on that later.

Fred Goldstein  01:51

Fantastic. So let's begin with with discussing a topic that's a lot of interest in population health, and I was very excited to see that it was covered at the ACR convergence 21 conference, and that's of health equity, and looking into disparities in treatment, and approaches, etc. And I know that one of the presentations was on racial and ethnic disparities and treatment for Rheumatic Diseases at a large medical center by Rebecca Arroyo. I hope I pronounced her name correctly. Why don't we discuss that to begin with?

Atul Deodhar  02:20

Yeah, so um, this is absolutely a very, very important topic. And we are, it's about time that we are waking up to this problem. There is a racial heterogeneity in the US population in different parts of the country, and it is imperative for us to study the racial differences in several things. First is: how does the disease even present in different different populations is the clinical presentation very similar? Are the clinical presentation different? So the clinical characteristics could be different, depending on the race. And just to give one example of this is that in African Americans, lupus nephritis, we're not talking about that, but just lupus neprhitis, is extraordinarily worse, much worse, in African American's compared to lupus nephritis, in Caucasians, and the drugs may not work in a similar fashion. So medication use, so availability of the medication and what types of insurance these people have, and the social deprivation or the area where they're living. All of this plays into this, the what kind of formulary their insurance company allows them to use which drugs they want to they are allowed to use. And then the comorbidities are also very different in different racial population. So from all these points of view, the racial disparity in treatment, the comorbidities in patients with entire rheumatic disease spectrum is very important. At this ACR 2021 meeting, there were several presentations. The one that you are mentioning was an interesting presentation from a large urban center, and they were looking at the treatments that were given to patients with African American versus Caucasian for rheumatoid arthritis, and systemic lupus, and the good news. I mean, I was very happy that reading that and attending that abstract, was that patients with African American racial background, the most common insurance that they had was Medicaid, which we know has got some restrictions on what drugs we can use. However, what they found out was when they were looking at novel and targeted therapy for rheumatoid arthritis and systemic lupus. There was no difference, no difference between Caucasians and African Americans. So I thought this is very good, at least that particular Urban Health Care Center, they are providing equal care type of care, irrespective of the patient's  ethnic background. Now, one thing that they did not measure is what percentage of patients do not have any insurance. And this is, this is a difference between population study as well as, as opposed to diagnostic study. They can only study the people who come to their urban center, right? So they have some insurance. And in those patients coming to their urban center hospital, there is no difference in the treatment between Caucasians and African Americans, which in itself is a very good thing. But then you should go in the population, and then you find out what percentage of patients African Americans do not even have an insurance and haven't gone to the hospital, and what percentage of people, Caucasian patients do not have insurance and have not gone. My educated guess is that there is much more disparity there. And African American patients may not even have the luxury of going to the hospital and receiving the care. But that was one abstract. The second abstract was from Cleveland, and this was racial disparities in the comorbidities in patients with psoriatic arthritis, which is my research interest. And there they looked at a retrospective study. Here, in fact, even though the study was from Cleveland, they looked at kind of the entire nation, they use this very interesting IBM Platform, which is a research informatics tool which kind of goes to server behind the firewall of 20 major integrated healthcare systems in the US. Very interesting way of looking at the entire country. And there is that firewall, so you're not breaking the patient's identity. But then there are several things you can find out using this IBM Explorys, this platform, and they were looking at the comorbidities in patients with diagnosis of psoriatic arthritis. As I was mentioning earlier, psoriatic arthritis patients have significant other comorbidities. Metabolic syndrome, diabetes, hypertension, hyperlipidemia, ischemic heart disease, stroke, etc, etc. is much higher in psoriatic arthritis patient compared to general population. So these authors of this abstract looking at the comorbidities wanted to look at these comorbidities, including even osteoporosis, fibromyalgia, depression, etc., and then looked at a large number of patients using this platform, something like north of 26,000 patients, and they found out some interesting things that when it came to Caucasians. Hypertension, diabetes and obesity, and gout that was more prevalent in African Americans compared to Caucasian. However, malignancy, osteoporosis and anxiety was more prevalent in Caucasians. Now, again, these are patients with psoriatic arthritis. And it is, it was kind of curious to see how two different racial groups have different comorbidities. I'm not surprised with the hypertension, diabetes and obesity being more common in African Americans because that actually, even if you take general public who do not have psoriatic arthritis, African Americans probably have higher obesity, diabetes, hypertension and that comorbidity compared to Caucasians. But in psoriatic arthritis, the same thing is reflected. It was, I was interested in finding out for some reason, malignancy, osteoporosis and anxiety was higher in Caucasians. And these are a good research study is one, which in fact, raises more questions, not answers your question, and this is a one such study that, this kind of then raises interesting hypothesis. And this makes us question: why? Why is it that certain comorbidities are higher in one race compared to the other. And from that point of view, I thought this was a very interesting abstract from Cleveland. Though, of course, they looked at the entire country, but fit to your original point, the health care inequalities, not equality, it's a major point, and in some areas we're making progress. As the first abstract that I discussed in some areas, a lot of work needs to be done going forward.

Fred Goldstein  09:23

And you know, from a physician perspective, which ones of these various comorbidities are, are potentially more community based versus coming from the disease itself? For example, I would imagine that individuals who have psoriatic arthritis and are living with that pain might have more anxiety or stress because of the disease itself, versus coming in with other comorbidities associated with other issues.

Atul Deodhar  09:51

And you're right. And so we have noticed this connection between metabolic syndrome. Metabolic syndrome contains obesity, diabetes, hypertension, hyperlipidemia and that is that those are the risk factors for developing congestive coronary artery disease and cerebrovascular disease. So heart disease, heart attack or stroke - for some reason, this is extra. This is much more common in psoriatic arthritis patient compared to age- and sex-matched general population. We have found the same thing in rheumatoid arthritis, same thing in Ankylosing Spondylitis, same thing in lupus. And so we believe part of this at least is related to the inflammation. However, that doesn't really explain everything, and we need more research into why is it that metabolic syndrome is more common in inflammatory arthritis, compared to general population? And to answer to your question Fred, this. This is where the combined management comes into play. At our clinic at OHSU, we try to provide this combined management to the patient with psoriatic arthritis. Of course, dermatologists are the basic people who are going to provide the care for their skin and their musculoskeletal system. But then we cannot forget that they have this important aspect of depression and anxiety related to the disease itself. Nobody wants to go into public when they are got this kind of skin rash on their face, and on their arms, and etc., and they want to cover themselves and sit at home. So depression and anxiety is an important aspect of the disease. And then we also have to involve our colleagues from cardiovascular medicine, from endocrinology for diabetes, some to help our patients to lose weight, and then there are so much advances in that field as well. And we do involve our colleagues from psychiatry, our colleagues from endocrinology, our colleagues from cardiovascular medicine, in the treatment of a patient with psoriatic arthritis, because these other comorbidities that these patients have.

Gregg Masters  12:02

And if you're just tuning in, you're listening to the AMCP Podcast Series powered by PopHealth Week, we were 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 Doedhar, Professor of Medicine and Medical Director of Rheumatology Clinics and the Division of Arthritis and Rheumatic Diseases at Oregon Health and Science University,

Fred Goldstein  12:31

And, you know, speaking of your clinics, etc, we've seen a number of different ways to integrate various practices and specialties together, and you're seeing primary care bringing mental health practitioners either into their practice or available via telehealth to their patients. Are you sort of integrating more of these various specialties into the practice itself and and working as a team on the patients? Or is it still more of a referral model in and out?

Atul Deodhar  12:57

Yeah, it is. We started as a more sort of model, which was, we actually had a specific mental health professional attached to our clinic over the years. Unfortunately, with changes in the healthcare system, it has become more sort of, unfortunately, it has become fragmented. We have to refer the patient, and it also depends on the the insurance that the patient has, and what is allowed, and what is not allowed. But this is a very important population health problem that the mental health of these patients is extraordinarily important. Currently, we are referring our patients to psychiatry or psychology, to help them with their depression and etc. We, at present, have moved to that particular model.

Fred Goldstein  13:49

And I assume you're on an integrated medical record platform or something that links these various groups.

Atul Deodhar  13:55

Yes, yes. So, absolutely. So being at the university, that is the advantage that we have integrated the platform, and what I write my colleague from cardiology, or mental health, or dermatology can read in one day, right, I can read, and then that's the beauty. That certainly is definitely helping us for a combined approach to the management of the patient. And I think I do want to, since we're talking about the comorbidities, at some stage, I do want to tell you about an important comorbidity, which is, which was discussed at the American College of Rheumatology meeting, and that is fatigue, which also in some ways is related in this whole equation of anxiety, depression. Fatigue is part of that anxiety, depression thing, but it's also part of the inflammation, and that this is one of the complaints that the patients have that we actually had neglected for very many years. And there was a lot of information about that in this meeting, but I will, I'll wait. If you want to ask me more about the other thing. but otherwise we can discuss this.

Fred Goldstein  15:02

Yeah, and I think it'd be fantastic to get into that area. I know you talked about the diseases, you know, some of these areas striking younger people are in the workforce, etc. And I would assume that fatigue, which you mentioned is one of the comorbidities, would have a lot of impacts across a number of areas for that individual.

Atul Deodhar  15:18

Yeah, psoriatic arthritis patients, if you ask them, "What is ailing you the most? What are your two top complaints?" They say, pain and fatigue. A part of the service is called the rheumatologist. Of course, they've got skin as their major complaint, with their skin looking bad, and inflamed, and hurting, and itchy, and "I don't want to go into public with my skin rash." But it does is one of the top three things in psoriatic arthritis. So pain, skin, and fatigue, I should say. And that fatigue is clearly multifactorial. And we mentioned, depression, and anxiety makes you fatigued. If you're depressed and anxious, that itself causes fatigue. But the other thing we have been thinking is inflammation, of course, has a role to play in fatigue. And there could be other things that we don't even understand why they have fatigue. It could be because you're not sleeping well, because they're eating because of their skin. And so, in general fatigue has been kind of shunned from the research for all these years. We are now looking at fatigue in much more scientific manner, and this is a very positive development, as far as I'm concerned, from the patient care point of view, and also from the science point of view. So at this annual meeting, American College of Rheumatology Annual Meeting, we presented our work. We looked at fatigue in one of the clinical trials - actually, two clinical trials that we did on a drug called gesulkemab, which is pure IL 23 inhibitor. And we analyzed the fatigue using an instrument called the Functional Assessment of Chronic Illness Therapy. its called FACIT fatigue. The instrument is kind of well-validated in measurement of, it's a scale, it's a patient reported outcome, but it measures the level of fatigue, the effect of the fatigue on your productivity, etc, etc. And then we wanted to find out that which are the factors which define fatigue, what are the causes of fatigue. So we did this fancy principal component analysis. It's a statistical way of looking at what components at baseline tell you about this traffic fatigue, which is the way you're measuring it, and we found four important components. One was disease activity related, as we expected. Disease activity explains about 28% of the patients fatigue, joint related, which is joint pain, joint swelling, of course. And you can intuitively think that, yes, my joints are hurting, my joints are swollen, my joints are painful, enthesitis, etc. That explained about 15% of the fatigue. Skin, also a very, very important aspect of the disease. That explains about 10% of the fatigue, inflammation related fatigue, and this is we measured their anemia, we measured the reactive protein supplementation that inflammation explains the 40. But the interesting part was 38% of their fatigue is still unexplained. Doing our principal component analysis of everything that we know to measure in our patient of psoriatic arthritis, we can only explain 60 to 63% of their fatigue, 38% of which is the biggest aspect of their fatigue, is still a mystery. We have got no biomarker for this. We don't know what is the cause of fatigue. Is it some kind of neurotransmitters? Is it related to the depression? Is it related to which, which we did not measure in this study? And I have a feeling this 38% is, going back to our earlier discussion, anxiety, depression, lack of sleep. Related to that is probably making this target person, but I'm making the same point again, good research is where more questions are raised, and gives you a more direction to look at. This is one such research, and that fatigue is extraordinarily important. I don't want to stress it again, but it does affect patients life in general, their productivity, their work productivity, that absenteeism, that presenteeism: all of this is affected by the quality of life. Ultimately, the treatment goal is to give patients good overall quality of life, and fatigue is a major, major important aspect of that, and I'm happy that we are looking at it more carefully now.

Fred Goldstein  19:44

And obviously, as you mentioned, these different reasons or causes of fatigue require different approaches, which is why you put together a team to to work with and help these individuals in terms of treatment etc. Are there studies that now show what are there, various products improve that fatigue level for individuals?

Atul Deodhar  20:05

Yeah, so this was one of the first studies which specifically looked at fatigue, the gesulkemab  study. There are some studies from in the rheumatoid arthritis arena. Some of the JAK inhibitors Upadacitinib has shown that it improves the fatigue. So I'm happy that we as a community are taking fatigue more seriously. Generally, because rheumatologists used to think that, "Oh, fatigue? This is all psychological stuff. I don't know what to do with this, deal with this, etc. Go somewhere else." We are now taking active interest and seeing whether our biologics and our novel synthetic therapies such as the JAK inhibitors: are they helping the patients? One of the three most important problems that the patient wants you to take care of. And this is a very positive development. That actually brings me to another important aspect, which I wanted to discuss very quickly, is individualizing the therapy, and this is also goes into the safety aspect of that and of a drug. Patient that comes to you, one has to individualize therapy, that would be actually personalized medicine, and that's where the field is going. We are not yet there, but we cannot really say that in this particular patient, this particular drug is going to be important based on these biomarkers, based on their genetic background, based on their imaging, etc, etc. However, this actually is a good segue in this individualized treatment. Not everybody has fatigue as their major issue. They have got other issues. They got pain issue. They have got inflammatory bowel disease along with their psoriatic arthritis, and we have to take into account, "Oh, well, what treatment should I be giving this particular patient? Because IL 17 inhibitors, I cannot use in patients with inflammatory bowel disease, or they may have uveitis." Here again, I'm talking about the patient as a whole. It's not just their joint aches and pains, which is what as rheumatologists we are interested in, but they might have uveitis, which is a feature of their psoriatic arthritis, inflammatory bowel disease, which is a feature for them. Fatigue might be for some patients, that might be the most important thing. So individualizing the treatment is also taking into account, what is the biggest problem for this patient? And I ask this question, then I see the patient. If there is one thing that I can do today, which is going to help you the most, what would it be? Is it your eye? Is it your gut? Is it your fatigue? Is your pain? Is it your knee joint? Or is it your Achilles tendon? What can I do for you? Which is going to be making the most impact? And we need to take that approach and help the patient and involve our colleagues of other specialties who might be, who will be better than you in taking care of that issue. And that's the individualized treatment that we need to be applying to our patients.

Fred Goldstein  23:04

Sounds also like you're using a very collaborative approach with your patients. They're part of your approach.

Atul Deodhar  23:10

Yes, yes.

Fred Goldstein  23:11

So as you look to the future, what do you see out there are things that might excite you, or things that other payers or health plan should consider or be looking at now?

Atul Deodhar  23:23

There are several newer drugs which are coming, which are on the horizon. So just to give you some examples, there was a - there is a drug which blocks IL-17A and IL-17F Bimekizumab. This is, we only have drugs currently which block IL-17A, which is secukinumab) and ixekizumab. Now whether Bimekizumab is going to be a an advance over IL-17A and IL-17F inhibition, we'll have to wait and see. There is a drug that blocks TYK2. So just like JAK inhibitors, we know which TYK inhibitors, TYK tyrosine kinase inhibitor. TYK2 inhibitor is a pill and that's in the arena of this JAK inhibitors as oral pills. That's an advance, because patients, many patients, this is again, individualized therapy, like oral therapy over injectable therapy. And again, linking to our earlier discussion about fatigue and depression and anxiety, these newer drugs will be put to test as to, are they helping the patient as a whole? Do they help the patient's extra articular  manifestation, extra musculoskeletal manifestation? What is ailing the patient the most? How are they controlling the inflammation, anemia etc.? These are just two examples. But there are several other drugs which are in development. IL-23 inhibitors is a newer class of drug that we already have one drug approved for the treatment of solid, actually two drugs now since the ACR Convergence Guselkumab and Tildrakizumab , but there is one more drug that is probably could get approval for axial spondyloarthritis. There are drugs which are coming into the market, which are blocking GM-CSF, another cytokine. And that has been shown to be effective in controlling the pain in patients with rheumatoid arthritis. So we are looking at that in axial SPA, as well. So, lots of interesting drugs looking at the, on the horizon. And then one more thing which I want to quickly mention is this personalized medicine. Patient sitting in front of me, I need to know, what would be the drug that is most important for that patient. Again, looking at what important domain of the disease, the patient has biggest problems with. So personalized medicine, the more we learn about the how the genes, genetics and environmental factors are shaping this person's disease, gut microbiome B. That's a different topic altogether and different discussion. A lot of interesting part about gut microbiome out there.

Fred Goldstein  26:03

Well, that's a fantastic way to end the show, and probably see about bringing you back on in the future to discuss some of these other issues you raised. So Dr. Deodhar, thank you so much for joining us.

Atul Deodhar  26:13

Thank you very much for giving me the opportunity.

Fred Goldstein  26:15

And back to you, Gregg.

Gregg Masters  26:16

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 Rheumatologists Convergence 2021 conference, go to www.ACR21AMCP.AMCPmeetings.org, 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. PopHealth Week streams live on healthcare now radio.com at 5:30am, 1:30pm and 9:30pm Eastern and 2:30am, 10:30am and 6:30pm Pacific. Bye now.