Anti-synthetase syndrome associated interstitial lung disease after combination dual immune checkpoint inhibition.

Immune checkpoint inhibitors (ICIs) unleash potent anti-tumour responses but with frequent off-target immune-mediated adverse events (irAE). ICIs can induce a spectrum of rheumatologic manifestations including inflammatory arthritis, Sjögren's syndrome, scleroderma and systemic lupus erythematosus. Here, we describe a case of antisynthetase syndrome associated interstitial lung disease (ILD) following dual Programmed Cell Death 1 and Cytotoxic T Lymphocyte-Associated Protein 4 checkpoint inhibition in a patient with metastatic melanoma. Initial treatment course was complicated by a number of irAEs including pneumonitis, colitis and thyroiditis. Suspicion of an underlying systemic rheumatic disease was heightened by the severe, relapsing and fibrosing nature of the interstitial pneumonitis. A diagnosis of amyopathic antisynthetase syndrome was made upon detection of circulating aminoacyl-tRNA synthetase (anti-EJ) autoantibodies. Intensification of induction immunosuppression followed by maintenance mycophenolate, prednisone and monthly intravenous immunoglobulin achieved long-term disease control. Detection of de novo ICI-induced inflammatory myositis ILD requires a high index of suspicion and carries important prognostic and treatment implications.

Survey of Australasian Renal and Rheumatology Specialists investigating topical NSAID use and adverse renal outcomes.

INTRODUCTION: A survey investigated physician reported use, prescribing practices and adverse renal events of topical NSAIDs. METHOD: This survey was sent to members of the Australian Rheumatology Association and the Australian and New Zealand Society of Nephrology. RESULTS: Sixty physicians responded, 55% (n = 33) were nephrologists; 45% (n = 27) rheumatologists. Nearly all (n = 56, 93.3%) had managed at least one patient using topical NSAIDs, including those with an eGFR <45 mL/min (n = 55, 91.7%). Concern was expressed that patients may use topical NSAIDs without the physician's knowledge. The majority (n = 40, 66.6%) have prescribed (or recommended) a topical NSAID, slightly less in patients with a reduced eGFR <45 mL/min (n = 36, 60.0%). Participants would advise topical NSAIDs for osteoarthritis and musculoskeletal pain, though be mindful to monitor the renal function and blood pressure. There was a variance in comments in advising use in CKD (eGFR <45 mL/min) from avoidance in those with an eGFR <30 mL/min to minimal concern. Most respondents (n = 55, 91.7%) had not encountered an acute kidney injury (AKI) suspected from topical NSAID use. Of the five that did, three were thought to be an adverse renovascular event and two were uncertain. All patients had an eGFR <45 mL/min, all had recovery f their renal function with NSAID cessation. DISCUSSION: Patients commonly use topical NSAIDs, often without the physician's knowledge. Most respondents would recommend their use in osteoarthritis and musculoskeletal pain, though with caution in CKD. While an AKI is uncommon due to topical NSAIDs, it may occur, especially in those with CKD.

A survey on the beliefs and knowledge of gout management in new medical graduates - New South Wales, Australia.

AIM: To assess the beliefs and knowledge of gout management in new medical graduates. METHOD: A survey on gout management was sent to new medical graduates during their orientation week, New South Wales, Australia. RESULTS: Of 15 hospital networks, 11 agreed to participate. From these, 168 graduates responded (23.7% response rate). Most (81.1%) felt that gout was a serious disease, 51.2% answered that they had been taught adequately to manage acute gout, only 37.2% for chronic gout. In an acute gout flare, 63.4% answered they would continue urate lowering therapy and 67.2% were aware of first-line pharmacological management options; 28% answered the correct dosing regimen for colchicine. Chronic management was answered poorly. Only 42.0% stated they would titrate allopurinol dosing to a target urate level; 23.5% would check the urate level monthly. More than half, 56.8%, were aware that medical prophylaxis is indicated when initiating urate lowering therapy. Of this subgroup, 46.7% (25.9% overall) knew that non-steroidal anti-inflammatory drugs and colchicine were recommended and 28.4% (15.4% overall) answered the correct timeframe of use. Close to one-third (35.0%), were aware of febuxostat, probenecid and benzbromarone as second-line urate lowering therapy. CONCLUSION: The findings of this study suggest that new graduates' knowledge of gout management, especially chronic management, is suboptimal. Many felt their teaching on gout management inadequate; this is a potential target for intervention. Up to date university education which covers chronic management may lead to better clinical outcomes for this burdensome disease.

A survey of the assessment and management of gout in general practitioners and medical officers within the Illawarra Network, Australia.

AIM: To review the assessment and management of gout by general practitioners (GPs) and medical officers (MOs) within the Illawarra Network, Australia. METHOD: A survey was sent to GPs and MOs within the Illawarra Network. RESULTS: Of 110 GPs, 45 responded. Of 129 MOs, 42 responded. The overall response was 32.6%. On analysis, 65.1% felt their knowledge of gout to be adequate and 61.6% thought they had been educated well. In acute assessment, 59.1% of GPs responded that the diagnosis of gout best be confirmed with a joint aspiration and 36.4% clinical suspicion. Differing, 85.7% of MOs chose a joint aspiration. In acute management, if colchicine were used, 59.1% of GPs would give 1 mg followed by 0.5 mg an hour later, then 0.5 mg twice daily, compared to 9.5% of MOs, while 20.5% of GPs would use 1 mg twice daily. Chronic management was answered poorly. After an acute attack, urate lowering therapy (ULT) would be started 14 days after by 47.7% of GPs, compared to 69.0% of MOs. GPs were more likely to start ULT within 7 days (52.3% vs. 31.0%). With dosing of ULT, 45.3% would treat to target, while 46.5% would dose to the creatinine clearance. Prophylactic therapy with ULT would be started by 81.8%, although only 17.4% would continue it for 3-6 months. CONCLUSION: There is poor adherence to recommended practice for dosing of colchicine in acute gout. Also in the management of chronic gout, in particular, the timing of starting ULT and the use of prophylaxis when initiating ULT.