‍Rick Pope MPAS, PA-C, DFAAPA, CPAAPA, is an Author, Clinical Professor at University of Bridgeport PA Institute, Sacred Heart University PA Program, Rheumatology PA (emeritus) Department of Rheumatology, Danbury Hospital, Danbury, CT and Founder and Past President, Society of PAs in Rheumatology.

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Introduction

Welcome back to MEDS eNews. For this issue, I spoke with Rick Pope MPAS, PA-C, DFAAPA, CPAAPA. Rick was a past faculty at the recent MEDS Summit and is faculty at the upcoming Metabolic & Endocrine Disease Summit Fall (MEDS). 

In this issue, Rick shares valuable pearls from his upcoming MEDS Fall presentations, and we also discussed several critical components of MEDS care specific to osteoporosis and rheumatology treatment options. Don’t miss the Rapid Fire! segment where Rick weighs in on some interesting topics as well.

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MEDS Fall, held in-person from October 12-14, 2023 in Orlando, Florida, will bring you:

• The latest cutting-edge knowledge and clinical breakthroughs in metabolic and endocrine diseases—diabetes, thyroid and adrenal disorders, obesity, and everything in between, to make a lasting difference in your patients’ lives!

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Sessions include: 

•    Women’s Health and Endocrine Considerations
•    Thyroid Considerations and Cases
•    Addressing CKD With Diabetes
•    Diabetes, Metabolic Disorders, and Osteoporosis
•    Metabolic Disorders and Rare Endocrine Diseases You Can’t Miss
•    Insulin Options: Proper Utilization Through Case Studies

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It’s a one-stop shop to get you up to speed with CME, with an emphasis on interactivity with panel discussions, Q&A, and case studies. Register here

Thank you this month to Rick Pope for all of his time and effort. Please contact me at colleen@cmhadvisors.com with comments or suggestions. Thanks for reading MEDS eNews!—Colleen Hutchinson

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Rick Pope MPAS, PA-C, DFAAPA, CPAAPA Weighs In

Author, Clinical Professor University of Bridgeport PA Institute, Sacred Heart University PA program, Rheumatology PA (emeritus) Dept of Rheumatology, Danbury Hospital, Danbury, CT Founder and Past President Society of PAs in Rheumatology.

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What are the best labs for assisting in the diagnosis of rheumatic disease?

Rick Pope: The history is the most important part of any rheumatic disease diagnosis, as it is with most diseases. The history should often focus on joints, skin, mucosa, hair, muscle, lung, and heart. My biggest efforts in teaching rheumatology are to focus on multiple systems that could be affected. Also, your patient’s sex and age will immediately help to narrow your differential diagnosis.

Once the history is taken and I am leaning in one direction or another, I will almost always get a CBC, ESR, CRP, and Comprehensive Metabolic Profile. Be sure to pay attention to RFTs and LFTs—RFTs because many drugs have limitations for dosing or cannot be given at all, and LFTs looking for both hepatic causes along with ETOH use. Methotrexate also is metabolized through the liver, and you might want to avoid MTX in that instance. If you think gout, uric acid is very helpful. If you think RA or other systemic rheumatic disease, then a RF, anti-CCP, and ANA titer with staining pattern would be helpful.

There are so many rheumatic diseases, so having access to a rheumatologist in your area is key. Reach out to him or her, and I am sure they would be willing to help.

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Can you share any takeaways from your MEDS Fall 2023 session topics, Osteoporosis: Moving Osteoporosis Up the List and Case Studies: Putting Osteoporosis Management into Action?

Rick Pope: For more high-risk patients, both anabolics and sclerostin inhibitors reduce fractures and improve BMD quicker and to a larger extent than anti-resorptive medications. There are now many trials, both RCT and retrospective analysis, that clearly demonstrate the superiority of a more aggressive approach in patients with high risk. There are those that believe all patients needing a medication should be initially treated with these more potent drugs to start and use of follow-on drugs after completion.

Osteoporosis is a lifelong disease and correct management with appropriate drugs can prevent future fractures. Too often patients believe they can be treated for a certain period of time, and that then they are finished. But this is not the case, and the sooner we educate the public and our patients that this disease is no different than hyperlipidemia or heart disease, the better off our population will be.

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How can I better maximize my treatment for osteoporosis when I work in primary care, and I have limited access?

Rick Pope: Many practitioners have barriers to treating patients with parenteral medications for OP. Two of the most common are denosumab and IV zoledronate. These often require prior authorizations and will need to be referred to outpatient infusion departments for treatment. I urge my colleagues to provide a path for appropriate patients to these sites for treatment. Reach out to your endocrine or rheumatology specialists to see what they do for access. It is a good idea to have a direct line to the IV infusion department nursing staff as well.

Additionally, if there is a Fracture Liaison Service in your system, this is a great way to ensure that your patients are treated with the most up-to-date therapies for their particular situation.

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Rapid Fire with Rick Pope:

Most critical new advance in my area of medicine:  Romosozumab for high-risk patients to start and then sequenced to denosumab or alendronate as a followup.

My mentor: Mike Lewiecki, MD, University of New Mexico Bone Health Tele-echo

Best tool in my clinical arsenal: Physical exam and height measurement

What I wish the patient would remember: Selected exercises daily help keep bones strong. Balance and gait prescriptions should be used liberally. In my experience PTs know how to do these exercises routinely and are willing to do so.

The biggest challenge I face in caring for my patients: Simple lifestyle changes are not enough for many patients. For practitioners-give all the pros and cons of each medication and let the patient decide. 

Biggest reward in caring for my patients: Thank you from patients who appreciate the work that goes in to managing their disease. 

Potential impact of AI on metabolic and endocrine disease: Lateral spine x-rays enhanced with AI looking for silent fractures and how old they are. 

Rewarding case of recent: Successfully diagnosing a parathyroid adenoma who underwent a surgical resection. She wrote the hospital President thanking me.

Best tool in my clinical arsenal: Vertebral Fracture Assay (VFA) looking for compression fractures on a lateral view done during DXA scanning.

A common misunderstanding among patients: Stopping supplemental calcium and vitamin D once they have started on medication—believing that the medication all they need.

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