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2020 Rheumatology Year in Review

Jan 14, 2021 2:22 pm

2020 was historic, memorable and game-changing. Under the cloud of COVID-19, there were many significant and memorable advances and setbacks for the rheumatology world. In our accounting of most read articles for 2020, (not surprisingly) 17/20 were COVID-related. Below, are our top news items that rheumatologists should recollect and integrate into clinical standards for 2021 and beyond. 

  1. COVID-19.  While 2020 was all about the pandemic, it only gets one slot in this list. That being said, here are the top 10 COVID, rheum-notable developments and take-aways for 2020:
    • GRA: Rheumatologists unite to establish the COVID-19 Global Rheumatology Alliance registry
    • Telemedicine: 75% of Rheumatologists transform overnight to practice telemedicine
    • At Risk: Those at greatest risk for COVID and its consequences are patients on steroids and those with autoimmune disease that is active
    • Reduced Risk: A reduced risk of COVID and its consequences was seen among inflammatory arthritis patient treated with TNF inhibitors, JAK inhibitors and advanced biologics
    • Autoantibodies: COVID-19 complications are often associated with lupus anticoagulants and antiphospholipid antibodies and microthrombotic proclivity
    • Hydroxychloroquine: rose to fame, fell from grace, went into shortage – all in the span of 4 months in mid-2020
    • Colchicine, IL-1 inhibitors (anakinra), and IL-6 inhibitors (tocilizumab, sarilumab) were shown to work in multiple (but not all) studies
    • Baricitinib. November 2020, FDA issued an emergency use authorization for the combination of baricitinib and remdesivir in hospitalized COVID-19
    • MIS-C (multisystem inflammatory syndrome in children): a new Kawasaki-like disease appears in hundreds of COVID infected children
    • US mortality figures are up (more than 3.2 million deaths in 2020), at least 400,000 more than in 2019 (all due to COVID)
  2. New Drugs: In 2020 the FDA approved 53 new drugs and removed 318 drugs from the US marketplace. Unlike past years, the new drugs did not target a rheumatic indication.  Nevertheless, 2020 affirmed several new indications for previously FDA approved drugs including:
    • Simponi (golimumab) and Xeljanz (tofacitinib) were FDA approved for polyarticular JIA
    • Kineret (anakinra) and Arcalyst (rilonacept) were approved for use in DIRA – deficiency of the IL-1 receptor antagonist
    • Benlysta (belimumab) was approved for lupus nephritis
    • Nucala (mepolizumab) was previously approved for severe asthma and EGPA;  now approved for hyperesoinophilic syndrome
    • Otezla (apremilast) was approved for scalp psoriasis
    • Humira (adalimumab) has a new approval for 80 mg injection for use in hidradenitis supprativa and other disorders requiring 80mg dosing (e.g., psoriasis)
    • Tremfya (guselkumab) was approved for use in psoriatic arthritis
    • Ilaris (canakinumab) was approved for AOSD – adult-onset Still’s disease
    • Taltz (ixekizumab) and Cosentyx (secukinumab) were approved for nonradiographic axial spondyloarthritis
    • Voltaren (diclofenac) gel became available as an OTC product.
  3. Reproductive Health Guidelines. 2020 saw publication of ACR guidelines on the management of reproductive health issues in rheumatic disease (RMD) patients before, during and after pregnancy. This exhaustive review and recommendations address issues such as pre-pregnancy counseling, contraception, paternal medication, DMARD and biologic use during pregnancy and with lactation.
  4. FAST: Long-term efficacy and Safety of febuxostat was again put to the test, this time with FEB besting allopurinol in all-cause mortality, adverse events and even lowering of uric acid.  FEB getting a “Boxed Warning” from the FDA in 2018, now appears to be an over-reaction.
  5. IRAe's: Immune-related adverse events related to immune checkpoint inhibitors (ICI) have become commonplace given the widespread use of ICI immunotherapy for cancer.  The spectrum of rheumatic syndromes has expanded, but so has hour understanding of the immunopathogenesis and management of this complication. Importantly, it appears that tumor/cancer responses have not changed with our management of IRAe's. 
  6. JAKs Advance: While marketed JAK inhibitors (baricitinib and upadacitinib) are FDA approved for use in RA, and tofacitinib is also approve for use in PsA, ulcerative colitis and polyarticular JIA; there has been an expanding body of research showing the benefits of JAK inhibition in skin disorders (atopic dermatitis, eczema, alopecia universalis and dermatomyositis), psoriatic arthritis, and ankylosing spondylitis. And they're oral!
  7. EULAR 2019 and ACR2020 Guidelines for RA management.  Everyone loves guidelines (other than practicing rheumatologists).  Most of these recommendations make great sense and are a rehash of what’s known. What is new is how, when and in whom you can withdraw therapy and whether or not it’s safe to use methotrexate with lung disease, etc.
  8. Filgotinibs Reversal of Fate. Filgotinib, was to have been the next big drug in RA. A JAK inhibitor with great data and safety but on August 18th, Gilead and Galapagos received a complete response letter (CRL) putting off FDA approval of their JAK inhibitor for the treatment of RA. Largely because of unfinished safety studies regarding potential testicular toxicity and the safety of the proposed 200 mg dose. Surprisingly the manufacturers withdrew their application, despite filgotinib being approved for use in other parts of the world
  9. Systemic Sclerosis Hope:  Tocilizumab is down but not out as newer analyses show potential lung, but not skin benefits. Romilkimab (bispecific anti-IL-4/IL-13 antibody) was shown to be effective in phase II study. Also looking good in early phase II were tofacitinib, abatacept and ziritaxestat, an autotaxin inhibitor, was shown to be effective at Rodnan skin scores and ACR-CRISS, but not lung outcomes in patients with diffuse cutaneous SSc. 
  10. In Memorium: Gone but Not Forgotten; notable rheumatologists who passed away.
    • Harry Spiera, MD (1932-2020),
    • John "Tim" Harrington, MD 1940-2020
    • Raphael J DeHoratius, MD (1942 – 2020)
    • William Phelps Arend, MD (1937–2020) 
    • Evan Calkins, MD (1920–2020)
    • Luis R. Espinoza, MD (1943–2020)
    • Allen R. Myers, MD (1935-2020)
    • Mike Powell, MD (1954-2020)
    • Robert M. Bennett, MD (1940-2020)
    • John Winniett Digby, MD FRCPC (1930-2020)
    • Ian Reay Mackay, AM (1922-2020)
    • Isaac “Saky” Abadi, MD (1936-2020)
    • Kenneth M. Bahrt, MD (1953-2020)
    • David A. Minna, MD (1947-2020)
    • Edward P. Rose, MD (1946-2020)
    • Eric P. Gall (1941-2020)
The author has received compensation as an advisor or consultant on this subject

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