Michael Mallinson - Discusson about Axial Spondyloarthritis
Jayson:
Michael, welcome to this episode of the Ankylosing Spondylitis podcast. And based upon the introduction and what we're going to cover today, I may have to change that name at some point down the road. Welcome to the show.
Michael
Thank you, Jayson. And thank you for having me. And yes, there's certainly time to change terminology around our disease.
Jayson:
Well, I was diagnosed 35 years ago, things tend to change slowly. So hopefully, I'll get around to figuring that out and what I want to do and how we structure it, but you know, you and I met through a forum on Facebook that deals with ankylosing spondylitis and the whole disease structure itself. You've made multiple posts that have been met differently with people's reactions on why the correct terminology might not be calling the disease itself ankylosing spondylitis, but maybe better off calling it Axial Spondyloarthritis. Tell me a little bit about that.
Michael:
Well, I can I understand why people are married to the next Ankylosing Spondylitis because like you that's what I was diagnosed with. And after my disease onset 40 years ago, but times change the technology changes, and also the name Ankylosing Spondylitis was never a universally used name, still isn't. In many parts of Europe, especially German speaking countries, the disease is referred to as Mobis Bechterew. In Russia, for example, it's named after Vladimir Bekhterev who was a Russian doctor who documented some of the symptoms of Ankylosing Spondylitis, but it's also been called Marie-Strumpell disease as well after two researchers who described the disease but what's more important, from our point of view is that Axial Spondyloarthritis is very difficult to diagnose. Originally, it was diagnosed by X ray radio graphically. So back in 1973, people recognized that there was a very common association with the gene HLA-B27 and spondyloarthritis. And looking into that further, they started seeing that people with Axial Spondyloarthritis or then called Ankylosing Spondylitis had this radiographic stage. And that was used as a diagnostic tool. There are no diagnostic criteria for this disease, but there are lots of different classifications. So, if you had radiographic sacral sacral le itis, and you displayed some other spondyloarthritis symptoms like family history or morning stiffness, etc. You were diagnosed with Ankylosing Spondylitis, then MRI came into being in the 1970s By the 1980s it was out there in the general hospital population and in general use and people who could read MRIs started noticing that if they were taking an MRI of the sacroiliac joint, they could see sacroillitis. But was this the same as the sacroillitis evident by X ray in Ankylosing Spondylitis? And there was a long debate about that. And that debate really wasn't resolved until the last year or two. So it's now understood that what we call Axial Spondyloarthritis is a continuum of disease from what had been called non-radiographic axial spondyloarthritis through to radiographic axial spondyloarthritis. So it's all recognized as one disease. And the important thing about that is that to exclude people, from patient organizations from help and support from the treatments available for Ankylosing Spondylitis, because they have non-radiographic axial spondylitis writers is extremely unfair. The disease burden is the same. Somebody with non-radiographic axial spa has exactly the same symptoms, the same pain, the same stiffness, the same mental issues as somebody who they ankylosing spondylitis. There's a further important part and that is that we know from a lot of evidence that the earlier the treatment, the better the outcome for the patient. So if you're waiting 6,7,8,9,10 years for diagnosis, and you don't get onto a treatment plan, until you're sort of seven or eight years into your disease progress. That's pretty serious, because by then you could have disfigurement, you could have kyphosis, you could have fusion, etc. That could have been prevented if you had been diagnosed earlier. And treated earlier. So with the X ray, the big problem was that it takes about seven or eight years for sacroilitis to show up on X ray and MRI can see that sacroiliac status after about 18 months or 24 months from disease onset, so it's evidently better to get people on a treatment plan 18 or 24 months after disease onset than seven or eight years. And so as I say, I think that terminology is important to being all inclusive of this full spectrum of disease and to include those people who are diagnosed with MRI imaging in our discussion about axial spondyloarthritis, ankylosing spondylitis.
Jayson:
When you and I discussed this, obviously you're in Toronto area in Canada. I'm here just across the lake in Michigan and when I was diagnosed I was 14 years old, had had pain from about 9 or 10. It always had been attributed to, you know, “growing pains”. And when I went and saw my rheumatologist for the first time in 1984, he asked just a couple of basic questions and said, Tell me about this, this and this, this and this. He goes, you have Ankylosing Spondylitis. Now let's do the testing to prove what I think is going on. So for me, in my mind and my process, it was always you went to a rheumatologist. They asked you a few questions. You were diagnosed. They then did an MRI, which was a newer process, but he did X rays that an MRI, bloodwork and boom, you've got Ankylosing Spondylitis.
Michael:
Yeah.
Jayson:
Then I never met anybody else that had Ankylosing Spondylitis. So I didn't know that anybody else went through these 7,8,9,10, 20 year battles. So when I started hearing that from people I was like, wow, that's amazing. I had no clue that that even existed. It was really an eye opener for me.
Michael:
Well, maybe you're one of the lucky ones? But on the other hand, if you started with symptoms at nine, which is not altogether unusual, and weren't diagnosed until you're 14, the six years where you might have had more mental relief, because you because you could have known that it wasn't just in your head or just, you know, growing pains or something. And one of the things that you didn't quite address there didn't touch on is the male to female ratio because females are notoriously bad at being diagnosed and that doctors used to think of Ankylosing Spondylitis as a men's disease. I'll come back to that in a moment to a degree. But women take two years longer than men on average to be diagnosed. And part of it is because many of them were diagnosed erroneously, with fibromyalgia Instead of AS so when you show all these symptoms of pain and stiffness, etc Uveitis your doctor isn't up to date and doesn't know about Ankylosing Spondylitis as many GPs do not, then it's going to be a long, long, long journey to diagnosis, especially if people are looking for other reasons like Fibromyalgia or endometriosis or something and women.
Jayson:
Well, it was quite interesting. And again, a lot of my interaction with people is online. So one of the people mentioned something about women having degenerative disc disease. One of the things mentioned I saw online quite relevant was all these women kept coming back and saying I have degenerative disc disease. And I started wondering is that really the case? Or were you diagnosed with that beforehand, along with saying you had fibro or something of that nature? And then a third diagnosis of Oh now, you have non radiographic or you have Ankylosing Spondylitis, it's radiographic and really you don't have a degenerative disc disease. It's just a function of what's going on with the Ankylosing Spondylitis with the axial spindyloarthritis.
Michael:
Well, yes, and I understand the difficulty for women because some, you know, doctors some don't know a lot about Ankylosing Spondylitis to begin with, never mind the term axial spondyloarthritis. And of course, women present a little differently than men. Even with ankylosing spondylitis for men, it's usually in the sacroiliac joints, whereas women, they often start with pain in their hips and shoulders. So it doesn't actually first present actually. And so what's the doctor to do if they don't know that? And of course, the other difficulty is that about 90% of the population at some time or other, speak to their doctor about back pain. Of course 99% of that back pain is mechanical. Our interest is that 1% that is inflammatory back pain. So doctors may go off on the wrong direction right from the start and diagnose degenerative disc disease and not really be cognizant of the fact that there is an inflammatory back pain disease. But yeah, it's not an easy disease to diagnose. And what I hope the new terminology axial spondyloarthritis allows for is more an earlier diagnosis. And I also hope it's a term that's used more universally, it's used very, very widely in Europe. Now, in America, it seems that the knowledge translation is somewhat slower, and people have really not adapted this term yet.
Jayson:
Well, we take a while to change here. You latch on to something and it kind of sticks in where I was going with that is here in the States. One of the preeminent places for treatment of the spondyloarthritis is the Cleveland Clinic. And you made a very good point that I hadn't even paid attention to until I went and looked at the website was Dr. Khan, who is a very well known expert in in this disease and an author. His first book was just Ankylosing Spondylitis.
Michael:
It was
Jayson:
His second book was then Ankylosing Spondylitis - Axial Spondylitis. Now, his third book, his most recent one is just Axial Spondyloarthritis. He's taken a more holistic or a much larger, say 30,000 foot look at the disease and said, here's what we have. And as you pointed out, it's kind of removing that term of Ankylosing Spondylitis and trying to make a more generic or a more universally used term.
Michael
Well, it is a more universally or it has a potential to be more universally used and it also gets rid of this term, non-radiographic axial spondyloarthritis which is quite a mouthful. As I mentioned before the disease burden is the same between non-radiographic and radiographic stages of axial spondylitis arthritis. But there are some interesting differences with Ankylosing Spondylitis, which is the radiographic stage of axial spondyloarthritis. It's about two-thirds to one-third men to women. And it's not really clearly understood why the non-radiographic stage doesn't always progress to the radiographic stage. But Conversely, the non-radiographic stage we see more in women so it's two-thirds women and one-third men. So if you add the two together for axial spondyloarthritis as a whole, it's a one to one relationship and that's, that's important to note because women were poorly diagnosed and had a longer time to diagnose in the past. So the non-radiographic stage allows them to be diagnosed earlier. But the other thing about calling the whole disease spectrum, axial spondyloarthritis now as researchers, leading clinicians are starting to do instead of breaking it into the two stages is that it allows people with early non-radiographic stage of disease to have the same treatments that people with ankylosing spondylitis have, in other words, biologics. I don't know about the situation in the United States, but in Canada there's only one biologic actually approved for non-radiographic axial spondoloarthritis at this moment, I think they will all be approved eventually. But as we know, the earlier the diagnosis, the earlier the treatment, the better the outcome.
Jayson:
Sure and as we mentioned biologics, there's been debate raging across a lot of places and personally, I think the debate is driven by money, but many are, but there's that new class coming out which are biosimilars. Think of biosimilars as a generic for a name brand medication. So there's a huge, I don't know if there's a huge price discrepancy between a biosimilar and the name brand, as far as you know, when you and I as patients look at the medication costs, but I know there's a lot of dollars on the line for the manufacturers. So have you noticed in the Canadian side that there's been a lot of acceptance of the biosimilars from patients how, how has it worked on there because I, I've not even had a biosimilar ever offered to me here in the States.
Michael:
It's interesting, in the states you have a very, very, what is it devious, corrupt, medical system when it comes to the payment for medications. So in the States, you do not see a big price difference between the originator biologic and the biosimilar of that biologic. In Canada, it's a much much more pronounced difference. So, for example, if I look at Humira the well that's not a good example, let's look at Remicade. The Infliximab-dyyb, the actual biosimilar is about half the price, maybe 60% of the price of the originator. And so that's pretty significant and it's why there's been quite a discussion in Canada about the uptake and the acceptance of biosimilars. We unfortunately were subject to some misinformation propoganda in fact from some of the pharmaceutical companies I won't name them, but they were the ones whose biologics were coming off patent first. And they were telling patient organizations, that these biosimilars were not the same. They were similar but not the same. They were made in crappy facilities in crappy countries like Korea and India, and that there were problems with the naming convention so that, you know, people wouldn't know what drug they are actually on if it was the originator or the biosimilar. All of these things proved to be very, very wrong. And in Canada, I think we were fairly advanced about it patient organizations, at least some of them didn't have the wool pulled over their eyes with that propaganda and accepted the fact that biosimilars are the same as originators and how can I say that when they called biosimilars, I was very fortunate to attend the National Institute for bio processing research and training in Dublin, Ireland and quite a few years ago and see how bio logics are made and understand what biosimilars are. So the thing to understand about a biologic is that the biologic that you take today is not the same as the biologic that you took last time. And that's because the manufacturing process is so complex, that they can't always get it spot on. It's not like generic drugs, which are small molecule chemical drugs, a biologic molecule, it's a large living molecule, very, very complex, and the production is allowed within tramlines variance. So that variance happens in the manufacturing process naturally, and in fact, you can get a trend in one direction or the other. So, the Humira or the Remicade that you take in North America is not the same as the Remicade or Humira that you take in Europe because of this diverging trend from the original. When biosimilars were approved, they were approved, not on the basis of chemical trial of sorry, clinical trials. They were approved on their chemical similarity to the originator by biologic, they will give tighter lines of variants. So in fact, a biosimilar of Remicade is actually closer to the original Remicade than the Remicade may be that somebody is taking at the moment. Does that make sense?
Jayson:
It does. Yes. It's squirrely, but it makes sense.
Michael:
In fact, a biosimilar is closer to the original biologic than a generic drug is to its original chemical drug. And that is because when you look at a generic drug, I don't know what it is some sort of aspirin say, it's got fillers and stuff and you don't know what else it's got in. It's got its active ingredients, and then it's got fillers and adherence and stuff in there to hold it together in pill form. So it is less like the originator drug than the biosimilar is like to its originator, biologic, so they are in you know, it's the same drug. If you are taking Remicade and you go on to inflectra which is one of the biosimilars for Remicade. It's all the same drug, it's it's there is no difference. That is of any significance whatsoever. That's the thing that patients need to understand because in Canada, we have 19 different health systems here, each province read state, each province has its own healthcare system and then there's some healthcare systems for veterans, etc. But each province within its health care system has a drug formulary. And they decide on which drugs are going to be made available. And they negotiate the prices in conjunction with the other provinces with the manufacturers. So if a manufacturer is coming along and saying, hey, I've got a biosimilar and it's 4050 60% cheaper than the originator, those drug formularies are going to look up and say, Wow, we need to do this because our medical costs are going sky high. And you know, all these so called orphan diseases with specialist drugs and biologics are hugely expensive. We To decrease our costs, there's a huge saving to the health care system and society. If we allow biologics to be paid for by the province, then if they can reduce that cost with biosimilars, that's even better. And following the scientific evidence, they said, well, we're actually going to make patients switch from the originator to the biosimilar. And there was a bit of a hue and cry about this because of the, shall we say propaganda efforts put out by the pharmaceutical companies. But in the end, in the case of British Columbia, which was the first province to do this, there was a lot of hue and cry. But in the last analysis, the switchover went very smoothly and better than anybody expected, because one of the effects of the letters that pharmaceutical companies sent out to patients on that drug, telling them to be aware of biosimilars was Those patients took that letter to their doctor. Their doctor explained it properly. And they said, Oh, sure, I'll switch to the biosimilar. So it kind of backfired on them.
Jayson:
Laws unintended consequences.
Michael:
Yes, Yes, exactly. So in British Columbia, there was a very, very good uptake of the biosimilar. And that's now rolled out in Alberta. And it's coming to all the other provinces as well. And I think that's a good thing for society, because it means less cost in the healthcare system. And it's also a good thing because you take somebody who might otherwise not have been at work if they can get on a biosimilar now because it's affordable, and they're back at work, and they're paying taxes and, you know, sustaining society.
Jayson:
So is it the case where, like, if I, if I went 20 miles away, I'm in Canada, I'm in Sarnia. Yeah, if I was living there, which is part of Ontario, if I'm a new person, like I walk in the door, I'm diagnosed and they say let's try you on Remicade infusions. Am I going to get Remicade? Am I going to get the biosimilar? I'm going or am I going to get a choice?
Michael:
You will not get a choice new patients go on the biosimilar.
Jayson:
Okay and I've not heard any complaints. I've not seen anybody welling up and saying it, besides the fact that Remicade style medication might not be the appropriate biologic for you, I've not heard anybody say, the biosimilar isn't, and I guess you really wouldn't know if you're on a biosimilar whether it was better or worse than the actual name brand version, but I've not seen any welling up of people complaining one way or...
Jayson:
Michael, welcome to this episode of the Ankylosing Spondylitis podcast. And based upon the introduction and what we're going to cover today, I may have to change that name at some point down the road. Welcome to the show.
Michael
Thank you, Jayson. And thank you for having me. And yes, there's certainly time to change terminology around our disease.
Jayson:
Well, I was diagnosed 35 years ago, things tend to change slowly. So hopefully, I'll get around to figuring that out and what I want to do and how we structure it, but you know, you and I met through a forum on Facebook that deals with ankylosing spondylitis and the whole disease structure itself. You've made multiple posts that have been met differently with people's reactions on why the correct terminology might not be calling the disease itself ankylosing spondylitis, but maybe better off calling it Axial Spondyloarthritis. Tell me a little bit about that.
Michael:
Well, I can I understand why people are married to the next Ankylosing Spondylitis because like you that's what I was diagnosed with. And after my disease onset 40 years ago, but times change the technology changes, and also the name Ankylosing Spondylitis was never a universally used name, still isn't. In many parts of Europe, especially German speaking countries, the disease is referred to as Mobis Bechterew. In Russia, for example, it's named after Vladimir Bekhterev who was a Russian doctor who documented some of the symptoms of Ankylosing Spondylitis, but it's also been called Marie-Strumpell disease as well after two researchers who described the disease but what's more important, from our point of view is that Axial Spondyloarthritis is very difficult to diagnose. Originally, it was diagnosed by X ray radio graphically. So back in 1973, people recognized that there was a very common association with the gene HLA-B27 and spondyloarthritis. And looking into that further, they started seeing that people with Axial Spondyloarthritis or then called Ankylosing Spondylitis had this radiographic stage. And that was used as a diagnostic tool. There are no diagnostic criteria for this disease, but there are lots of different classifications. So, if you had radiographic sacral sacral le itis, and you displayed some other spondyloarthritis symptoms like family history or morning stiffness, etc. You were diagnosed with Ankylosing Spondylitis, then MRI came into being in the 1970s By the 1980s it was out there in the general hospital population and in general use and people who could read MRIs started noticing that if they were taking an MRI of the sacroiliac joint, they could see sacroillitis. But was this the same as the sacroillitis evident by X ray in Ankylosing Spondylitis? And there was a long debate about that. And that debate really wasn't resolved until the last year or two. So it's now understood that what we call Axial Spondyloarthritis is a continuum of disease from what had been called non-radiographic axial spondyloarthritis through to radiographic axial spondyloarthritis. So it's all recognized as one disease. And the important thing about that is that to exclude people, from patient organizations from help and support from the treatments available for Ankylosing Spondylitis, because they have non-radiographic axial spondylitis writers is extremely unfair. The disease burden is the same. Somebody with non-radiographic axial spa has exactly the same symptoms, the same pain, the same stiffness, the same mental issues as somebody who they ankylosing spondylitis. There's a further important part and that is that we know from a lot of evidence that the earlier the treatment, the better the outcome for the patient. So if you're waiting 6,7,8,9,10 years for diagnosis, and you don't get onto a treatment plan, until you're sort of seven or eight years into your disease progress. That's pretty serious, because by then you could have disfigurement, you could have kyphosis, you could have fusion, etc. That could have been prevented if you had been diagnosed earlier. And treated earlier. So with the X ray, the big problem was that it takes about seven or eight years for sacroilitis to show up on X ray and MRI can see that sacroiliac status after about 18 months or 24 months from disease onset, so it's evidently better to get people on a treatment plan 18 or 24 months after disease onset than seven or eight years. And so as I say, I think that terminology is important to being all inclusive of this full spectrum of disease and to include those people who are diagnosed with MRI imaging in our discussion about axial spondyloarthritis, ankylosing spondylitis.
Jayson:
When you and I discussed this, obviously you're in Toronto area in Canada. I'm here just across the lake in Michigan and when I was diagnosed I was 14 years old, had had pain from about 9 or 10. It always had been attributed to, you know, “growing pains”. And when I went and saw my rheumatologist for the first time in 1984, he asked just a couple of basic questions and said, Tell me about this, this and this, this and this. He goes, you have Ankylosing Spondylitis. Now let's do the testing to prove what I think is going on. So for me, in my mind and my process, it was always you went to a rheumatologist. They asked you a few questions. You were diagnosed. They then did an MRI, which was a newer process, but he did X rays that an MRI, bloodwork and boom, you've got Ankylosing Spondylitis.
Michael:
Yeah.
Jayson:
Then I never met anybody else that had Ankylosing Spondylitis. So I didn't know that anybody else went through these 7,8,9,10, 20 year battles. So when I started hearing that from people I was like, wow, that's amazing. I had no clue that that even existed. It was really an eye opener for me.
Michael:
Well, maybe you're one of the lucky ones? But on the other hand, if you started with symptoms at nine, which is not altogether unusual, and weren't diagnosed until you're 14, the six years where you might have had more mental relief, because you because you could have known that it wasn't just in your head or just, you know, growing pains or something. And one of the things that you didn't quite address there didn't touch on is the male to female ratio because females are notoriously bad at being diagnosed and that doctors used to think of Ankylosing Spondylitis as a men's disease. I'll come back to that in a moment to a degree. But women take two years longer than men on average to be diagnosed. And part of it is because many of them were diagnosed erroneously, with fibromyalgia Instead of AS so when you show all these symptoms of pain and stiffness, etc Uveitis your doctor isn't up to date and doesn't know about Ankylosing Spondylitis as many GPs do not, then it's going to be a long, long, long journey to diagnosis, especially if people are looking for other reasons like Fibromyalgia or endometriosis or something and women.
Jayson:
Well, it was quite interesting. And again, a lot of my interaction with people is online. So one of the people mentioned something about women having degenerative disc disease. One of the things mentioned I saw online quite relevant was all these women kept coming back and saying I have degenerative disc disease. And I started wondering is that really the case? Or were you diagnosed with that beforehand, along with saying you had fibro or something of that nature? And then a third diagnosis of Oh now, you have non radiographic or you have Ankylosing Spondylitis, it's radiographic and really you don't have a degenerative disc disease. It's just a function of what's going on with the Ankylosing Spondylitis with the axial spindyloarthritis.
Michael:
Well, yes, and I understand the difficulty for women because some, you know, doctors some don't know a lot about Ankylosing Spondylitis to begin with, never mind the term axial spondyloarthritis. And of course, women present a little differently than men. Even with ankylosing spondylitis for men, it's usually in the sacroiliac joints, whereas women, they often start with pain in their hips and shoulders. So it doesn't actually first present actually. And so what's the doctor to do if they don't know that? And of course, the other difficulty is that about 90% of the population at some time or other, speak to their doctor about back pain. Of course 99% of that back pain is mechanical. Our interest is that 1% that is inflammatory back pain. So doctors may go off on the wrong direction right from the start and diagnose degenerative disc disease and not really be cognizant of the fact that there is an inflammatory back pain disease. But yeah, it's not an easy disease to diagnose. And what I hope the new terminology axial spondyloarthritis allows for is more an earlier diagnosis. And I also hope it's a term that's used more universally, it's used very, very widely in Europe. Now, in America, it seems that the knowledge translation is somewhat slower, and people have really not adapted this term yet.
Jayson:
Well, we take a while to change here. You latch on to something and it kind of sticks in where I was going with that is here in the States. One of the preeminent places for treatment of the spondyloarthritis is the Cleveland Clinic. And you made a very good point that I hadn't even paid attention to until I went and looked at the website was Dr. Khan, who is a very well known expert in in this disease and an author. His first book was just Ankylosing Spondylitis.
Michael:
It was
Jayson:
His second book was then Ankylosing Spondylitis - Axial Spondylitis. Now, his third book, his most recent one is just Axial Spondyloarthritis. He's taken a more holistic or a much larger, say 30,000 foot look at the disease and said, here's what we have. And as you pointed out, it's kind of removing that term of Ankylosing Spondylitis and trying to make a more generic or a more universally used term.
Michael
Well, it is a more universally or it has a potential to be more universally used and it also gets rid of this term, non-radiographic axial spondyloarthritis which is quite a mouthful. As I mentioned before the disease burden is the same between non-radiographic and radiographic stages of axial spondylitis arthritis. But there are some interesting differences with Ankylosing Spondylitis, which is the radiographic stage of axial spondyloarthritis. It's about two-thirds to one-third men to women. And it's not really clearly understood why the non-radiographic stage doesn't always progress to the radiographic stage. But Conversely, the non-radiographic stage we see more in women so it's two-thirds women and one-third men. So if you add the two together for axial spondyloarthritis as a whole, it's a one to one relationship and that's, that's important to note because women were poorly diagnosed and had a longer time to diagnose in the past. So the non-radiographic stage allows them to be diagnosed earlier. But the other thing about calling the whole disease spectrum, axial spondyloarthritis now as researchers, leading clinicians are starting to do instead of breaking it into the two stages is that it allows people with early non-radiographic stage of disease to have the same treatments that people with ankylosing spondylitis have, in other words, biologics. I don't know about the situation in the United States, but in Canada there's only one biologic actually approved for non-radiographic axial spondoloarthritis at this moment, I think they will all be approved eventually. But as we know, the earlier the diagnosis, the earlier the treatment, the better the outcome.
Jayson:
Sure and as we mentioned biologics, there's been debate raging across a lot of places and personally, I think the debate is driven by money, but many are, but there's that new class coming out which are biosimilars. Think of biosimilars as a generic for a name brand medication. So there's a huge, I don't know if there's a huge price discrepancy between a biosimilar and the name brand, as far as you know, when you and I as patients look at the medication costs, but I know there's a lot of dollars on the line for the manufacturers. So have you noticed in the Canadian side that there's been a lot of acceptance of the biosimilars from patients how, how has it worked on there because I, I've not even had a biosimilar ever offered to me here in the States.
Michael:
It's interesting, in the states you have a very, very, what is it devious, corrupt, medical system when it comes to the payment for medications. So in the States, you do not see a big price difference between the originator biologic and the biosimilar of that biologic. In Canada, it's a much much more pronounced difference. So, for example, if I look at Humira the well that's not a good example, let's look at Remicade. The Infliximab-dyyb, the actual biosimilar is about half the price, maybe 60% of the price of the originator. And so that's pretty significant and it's why there's been quite a discussion in Canada about the uptake and the acceptance of biosimilars. We unfortunately were subject to some misinformation propoganda in fact from some of the pharmaceutical companies I won't name them, but they were the ones whose biologics were coming off patent first. And they were telling patient organizations, that these biosimilars were not the same. They were similar but not the same. They were made in crappy facilities in crappy countries like Korea and India, and that there were problems with the naming convention so that, you know, people wouldn't know what drug they are actually on if it was the originator or the biosimilar. All of these things proved to be very, very wrong. And in Canada, I think we were fairly advanced about it patient organizations, at least some of them didn't have the wool pulled over their eyes with that propaganda and accepted the fact that biosimilars are the same as originators and how can I say that when they called biosimilars, I was very fortunate to attend the National Institute for bio processing research and training in Dublin, Ireland and quite a few years ago and see how bio logics are made and understand what biosimilars are. So the thing to understand about a biologic is that the biologic that you take today is not the same as the biologic that you took last time. And that's because the manufacturing process is so complex, that they can't always get it spot on. It's not like generic drugs, which are small molecule chemical drugs, a biologic molecule, it's a large living molecule, very, very complex, and the production is allowed within tramlines variance. So that variance happens in the manufacturing process naturally, and in fact, you can get a trend in one direction or the other. So, the Humira or the Remicade that you take in North America is not the same as the Remicade or Humira that you take in Europe because of this diverging trend from the original. When biosimilars were approved, they were approved, not on the basis of chemical trial of sorry, clinical trials. They were approved on their chemical similarity to the originator by biologic, they will give tighter lines of variants. So in fact, a biosimilar of Remicade is actually closer to the original Remicade than the Remicade may be that somebody is taking at the moment. Does that make sense?
Jayson:
It does. Yes. It's squirrely, but it makes sense.
Michael:
In fact, a biosimilar is closer to the original biologic than a generic drug is to its original chemical drug. And that is because when you look at a generic drug, I don't know what it is some sort of aspirin say, it's got fillers and stuff and you don't know what else it's got in. It's got its active ingredients, and then it's got fillers and adherence and stuff in there to hold it together in pill form. So it is less like the originator drug than the biosimilar is like to its originator, biologic, so they are in you know, it's the same drug. If you are taking Remicade and you go on to inflectra which is one of the biosimilars for Remicade. It's all the same drug, it's it's there is no difference. That is of any significance whatsoever. That's the thing that patients need to understand because in Canada, we have 19 different health systems here, each province read state, each province has its own healthcare system and then there's some healthcare systems for veterans, etc. But each province within its health care system has a drug formulary. And they decide on which drugs are going to be made available. And they negotiate the prices in conjunction with the other provinces with the manufacturers. So if a manufacturer is coming along and saying, hey, I've got a biosimilar and it's 4050 60% cheaper than the originator, those drug formularies are going to look up and say, Wow, we need to do this because our medical costs are going sky high. And you know, all these so called orphan diseases with specialist drugs and biologics are hugely expensive. We To decrease our costs, there's a huge saving to the health care system and society. If we allow biologics to be paid for by the province, then if they can reduce that cost with biosimilars, that's even better. And following the scientific evidence, they said, well, we're actually going to make patients switch from the originator to the biosimilar. And there was a bit of a hue and cry about this because of the, shall we say propaganda efforts put out by the pharmaceutical companies. But in the end, in the case of British Columbia, which was the first province to do this, there was a lot of hue and cry. But in the last analysis, the switchover went very smoothly and better than anybody expected, because one of the effects of the letters that pharmaceutical companies sent out to patients on that drug, telling them to be aware of biosimilars was Those patients took that letter to their doctor. Their doctor explained it properly. And they said, Oh, sure, I'll switch to the biosimilar. So it kind of backfired on them.
Jayson:
Laws unintended consequences.
Michael:
Yes, Yes, exactly. So in British Columbia, there was a very, very good uptake of the biosimilar. And that's now rolled out in Alberta. And it's coming to all the other provinces as well. And I think that's a good thing for society, because it means less cost in the healthcare system. And it's also a good thing because you take somebody who might otherwise not have been at work if they can get on a biosimilar now because it's affordable, and they're back at work, and they're paying taxes and, you know, sustaining society.
Jayson:
So is it the case where, like, if I, if I went 20 miles away, I'm in Canada, I'm in Sarnia. Yeah, if I was living there, which is part of Ontario, if I'm a new person, like I walk in the door, I'm diagnosed and they say let's try you on Remicade infusions. Am I going to get Remicade? Am I going to get the biosimilar? I'm going or am I going to get a choice?
Michael:
You will not get a choice new patients go on the biosimilar.
Jayson:
Okay and I've not heard any complaints. I've not seen anybody welling up and saying it, besides the fact that Remicade style medication might not be the appropriate biologic for you, I've not heard anybody say, the biosimilar isn't, and I guess you really wouldn't know if you're on a biosimilar whether it was better or worse than the actual name brand version, but I've not seen any welling up of people complaining one way or another.
Michael:
Well, I haven't either, and I'm a little surprised by that. But then one thing that I learned about the American system is the people are switched between biologics all the time for insurance purposes and that's something that hasn't really happened in Canada, you go on one biologic and you stay on it, if it works for you, if it doesn't, as many of them tend to fail after a while, or maybe in 30% of patients, they don't work at all in the first instance. But if you find one that works for you, you stay on it. Whereas they discovered in the states that people often switch because they're working for an employer who is always looking to cut their costs and they switch their drug plan every five years or something. So people are forced to switch just because the drug plan won't cover their existing model or something like that.
Jayson:
It can be that’s not the way it usually works. If you're with insurance company A through your employer, and employer switches to Insurance Company B, and you're on co Cosentyx, let's say, well, there isn't a biosimilar that I'm aware of for Cosentyx because it's still patented drug. So the employers, the insurance companies say a biologic is a biologic is a biologic, you know, I don't understand any of the differences. I don't care too. All I know is that I'm paying $4,000 a month for Cosentyx and I can switch the guy over to a biosimilar of Remicade for $1,500 bucks, whatever the amount the math is. So they say no. Well, it's like a lot of things, the squeaky wheel gets the grease. They're going to send you a letter that says no, and you're going to go back to them and say, what I need it, you're going to come back and say no, and you're going to send a doctor's letter that says, Well, I need it. And then they're gonna say Well, no. And then your doctor is gonna write a third letter generally, a second letter might do it but generally the third letter says, Look, he's on Cosentyx, there is no alternative. And if he goes off Cocentyx, you're going to be looking at higher costs. Potentially for ABC, whatever a, b, and c is. And then these terms can be says, All right, well think about it, that think about it just means somebody has to look at it and say, yeah, this is going to cost us a whole lot more than this. Boom, you got you got it doesn't always mean it'll work that way. But it's generally if you push them hard enough. Now it's a little bit harder. For example, if you're on an anti-TNF when there's Remicade, Enbrel, Humira, there's a number of options that can be can be rolled into there, then they may push towards something different. But if it's working and your doctor writes the letter the right way. Yeah, chances are it will be approved.
Michael:
Yeah, but it is a hoop to jump through and as a person with a chronic debilitating disease, it's the last thing you want to be dealing with is hear something that helps me and all of a sudden I just got potentially the carpet yanked out from under me. And now I got to start this whole goofy process over that, you know, it's really a pain. It's
it is a pain and patients are not well equipped to do that because you're already suffering from fatigue and maybe anxiety and depression because of your disease and who wants to have to fight for it? That's not good. And I think there's a lot of advocacy to be done around that. And you mentioned Cosentyx, and that's an interesting case, because Cosentyx was a biologic that's made with much newer technologies than they had when the anti-TNF biologics were developed. So it was cheaper to produce. So Cosentyx even as an originator biologic is cheaper than the anti-TNF inhibitors.
Jayson:
Yeah, it's, it's really a squirrely situation with medical drug pricing. In the States, and again, I never took Remicade, I took both Humira and Enbrel and Cosentyx is more expensive than either one of those in the States. Yeah. But I also know drug company’s charge more for drugs here in the States. So they can charge less in other places, and use that as an offset. So it may be cheaper in Canada based upon contracts worked out with the Canadian drug company or not drug companies, but the health province healthcare plans. So it's always interesting to talk to somebody in different places to find out what they're paying for different drugs because here in the States, if our health insurance covers it, we generally don't pay a whole lot of attention, which is what they want. Whereas you may get a more detailed breakdown of what your medications cost, even if you don't pay them directly out of pocket. You still might get a better breakdown. I don't know And that could be different seen different in Germany and could be seen different in Australia?
Michael:
Yeah, actually one of my objections to the way drug pricing is done in Canada is that the negotiation point is taking a basket of prices from seven countries, one of which, one of which is the United States. And I think that skews the basket badly because drugs are so expensive in the States. And I think in Canada, we should throw that price out of the basket. Look at a lower cost. So in Canada, all the provinces used to negotiate drug prices individually, and then they got together in the pan Canadian coalition, if you like, and they negotiate on mass with the drug companies. And as they say, they use this basket of prices from other countries as a starting point and they want to drive it down. To that point, or somewhere near the average of that point in the States, I may have this one but I understand that there is no sort of large negotiating body. It's really between the manufacturers, the pharmaceutical companies, and the insurance companies and nobody else has much of a say in it. And then I understand that there's a kickback, there may be another nicer way of saying that a kickback from the pharmaceutical companies, to the insurance companies. So the insurance companies aren't motivated to negotiate for reduced prices. This is my understanding of why prices drug prices in the states are so high because you know, the insurance companies don't have that incentive to negotiate lower prices.
Jayson:
In that could be I you know, you've seen here in the States, there's been a push by many of the bigger insurance companies to buy their own digital tribution arms by pharmacies basically, yes. And so I think that is, if the terminology kickback is used, it was probably a negotiated payment for distribution or however you want to use it to offset different things. I'll use co Centex as again, as example. It's about $4,000 a month from my shots. So if I get that $4,000, but then I turn around and say, well, CVS, you're distributing it, here's $500 bucks for your problems. If I'm the insurance company, and I buy CVS, that all comes back to me in my corporate, basically, bottom line.
Michael:
Yeah, that is a very expensive drug. In US and Canada. It's about $1,000 Canadian dollars a month, while the Canadian dollar is worth whatever, you know, that's about $700-$800 bucks American so that's a huge difference.
Jayson:
When I took my first you know, with Cosentyx, they do a loading dose of five shots over five weeks. So at that point, I got the first dose in the mail and it had the price printed on it if you if you want to say, and the first dose was $4,300 and that was for one shot and so if you did five of those in five weeks, you're talking $21,000-$22,000 American.
Michael:
Yeah. Well, that's expensive. And I once had a conversation with the two guys who discovered TNF inhibitors such as Enbrel, he'll come back to me in a moment. But you know, they developed this and then it was sort of public property and then the pharmaceutical companies got patents,etc. So what these guys was saying to me was that they were disappointed that biologics weren't more accessible and weren't more widely available. And I guess they thought that the prices were extremely high. And they understand there's always a lot of cost in bringing a drug to market and then your patent runs out all too soon. But still, there are cheaper ways, especially with technology these days. You know, I was talking about that those trend lines of variants. Back in 2000, when the TNF inhibitors have been developed, they had machinery to move to measure that variance, right. The machinery that measures that variance now is a million times more sensitive and accurate than the machinery, the technology that they had just 20 years ago or so. Well, technology has moved tremendously. So these drugs can be made a lot more cheaply now, and that's why I think biosimilars are safe to take because they're measured much more accurately. They are the same as the originators. They're produced by some of the major pharmaceutical companies, you know, like Merck and Pfizer and what have you. So yeah, it's just like your original question about biosimilars. I see nothing wrong with them. And I think patients should accept them because patient’s premiums are going to be lower if they're paying less for biological intervention.
Jayson:
Yeah, and it's like anything else, it's really a matter of time. And well, there's not a biologic like I said for co Centex at this point. When you look at the biologics for if you're on Remicade, or I don't know there's one for Emerald but I imagine there probably is Based on how long that drugs been around, and I'm sure there's also one for Humira. Just those two alone, Remicade and Humira I believe are two of the most widely prescribed medications in the world, not just the states but in the world.
Michael:
They are, yes.
Jayson:
So the, the dollars on the line for the name brand versus the biosimilars are massive which is why I can certainly understand the the large companies not wanting people to start to shift over because these are really, these are really cash cow medications for him.
Michael:
You know what I said to one of the pharmaceutical companies when they were talking about defending their marketplace, Well, you know, if you're a car manufacturer and somebody came along with a better, cheaper car, what would you do? You will slam the car you want to say it's the piece of rubbish. It's a lemon. It's poorly made and all the rest you would go out and you would build a better car, you know, cheaper, higher quality car at the same price point. So why aren't you doing that with the drugs? I never got a good reply on that.
Jayson:
And you won't, because they don't have to. And until the way the US market goes is the way the rest of the world will go, so to speak. And if if the US market doesn't change, then it doesn't force slash benefit the rest of the world market. We've heard this by ordering drugs as Americans ordering drugs from Canada or bringing them in from Mexico, to drug companies will run ad campaigns here in the States about how safe it is to do that. Yeah, well, wait a minute. So the high blood pressure meds in Canada is not safe for them, and you're selling it to them, and only the one here in the states is safe for me, or are they the same meds just in a fraction of the cost? You don't want me to go get them there. Now, that was also not unfair to the Canadian are not fair to the Canadian healthcare system, because it meant that you as Canadian taxpayers, were then subsidizing American drug buyers.
Michael:
Yeah. So the funny thing is that those drugs that's a from Canada are FDA approved anyway. Because the Canadian Health Canada or its agency that actually approves the drugs, usually doesn't do it until the FDA is approved. There are some exceptions, but by and large, Canada follows the FDA is approach. Yeah, I've actually remembered the name of those two individuals who developed the TNF inhibitors that sir Marty Feldman and tiny Rainey tiny is his nickname because he's a very large man, very tall man. But it was Marty Feldman that I was speaking with who made that comment about he was the biological We're more accessible to more people. Yeah, you know, we think we have problems in North America, but then you think about people in, you know, in Bangladesh or Thailand or something where they don't have same infant health infrastructures.
Jayson:
Yeah, I know. I see quite a few people post from India. But once and I they have a fairly large and robust healthcare system, I believe in the cities, but the rule areas are a whole different ballgame and then when you head farther east from India, and you go through all of Southeast Asia, I think, again, in the metropolitan areas, you'll find a more robust healthcare system for those that can afford it and outside of that you're left to your own. I can't imagine dealing with a disease like this with with no access to any healthcare.
Michael:
Yeah, it must be quite alarming. Although I do have to say that to manage those diseases to take charge of your disease, I do think requires lifestyle changes. And I see quite a lot of people who are not really willing to change their lifestyle, they just want to pop a pill or eat tumeric or something, they they're looking for that silver bullet that will help them but you have to take charge of your own healthcare. You have to advocate for yourself. And you really have to change your lifestyle so that you can live life to the fullest.
Jayson:
Yeah, as a and I know I'm a I catch heck for this every time I go to the doctor, I'm probably carrying 50 pounds more than I should. And I've had bilateral hip replacements. And and the doctor is always on me about you know how much extra pressure that puts on your hips. So it's a good example here in the states that it's very challenging anywhere to make that adjustment. Just eating is a challenge. And I know that can reap huge benefits for any one with this condition.
Michael:
Well, it can and it's odd, isn't it? That's when I was diagnosed, first diagnosed 10 years after disease onset. I was told it's a men's disease and the people that I first came into contact with, who were fellow sponsors, were elderly, thin, white men. You know, but that's not the profile at all. I know over my years running the Canadian Spondylitis Association that the new demographic is largely female, and certainly not thin old white men.
Jayson:
I was told that by my doctor did. He did say that women could get it. But he said it's generally not as bad, which we know is not the case.
Michael:
Yeah, women's disease is actually worse than men's disease and
medical study.
Jayson:
Yeah, he mentioned at the time that it was primarily a disease with people with Mediterranean descent. And then it was funny because the first person I met that had ankylosing spondylitis was from Israel. And I said, Okay that just cemented that concept to me. And then all of a sudden, like, wait a minute, why are all these people from England getting this disease? Because that's certainly not a Mediterranean country. And it just kept saying, okay, we chip away at this. And now that rheumatologist I had had he just retired last year. And last time I went in to talk with him. We had a long conversation about this. He goes that diseases changed. He goes, this is one he says I, as a rheumatologist, there's a lot I have to know. And a lot I have to keep up on what he said. Ankylosing Spondylitis has kept me on my toes for the last 35 years, probably more than any other condition. Because every time you turn around, there's something new coming out and I have to determine, is this applicable? Is it just a study? Is there something anecdotal? He says, You're always having to determine how this fits into your patience? Does it fit into your patience and where you're going with this? So he was really, he was really forthcoming about just saying how much it's changed and how much he's had to re rethink his practice.
Michael:
Well, he's right. I mean, there are many many rheumatologists who don't know very much about axial spondyloarthritis or ankylosing spondylitis. And look at how it's changed in the past 30-40 years when I was diagnosed. I was told the prevailing servitors was one 10th of 1% of the population. We know that to be wrong. I was told it's the man's disease. We know that's to be that's wrong. So the actual prevailing sense of axial spondyloarthritis and spondee, low arthritis in general. So taking the group of diseases is now understood to be as common or more common than rheumatoid arthritis. So we're talking about 1% of the population 1.5%, not one 10th of 1%. And we're talking about the involvement of a lot of a lot of women who previously were ignored. You know, I know of one patient, female patient who is told that Oh, you just have achy female disease or something. Yeah, a totally irresponsible diagnosis.
Jayson:
Yeah, there's so much in the world. of this disease that is you said, You've got two thirds of one type, which is just as debilitating affects women and two thirds, the other and there's a crossover and everybody that has non radiographic won't develop into radiographic. But everybody has got radiographic sometimes started off in the non, and it just kept progressing. And so, the one thing I like to say about about this disease is it's, it's the disease that keeps on giving. And it just as soon as you think you might know something about it, or that something's concrete, be prepared, that means it's likely to change.
Michael:
Well, yeah, I mean, not everybody who progresses to the radiographic stage will actually progress to fusion either. Correct. So that's, that's a little confusing. And anyway, that's it keeps on giving accepted A few of us lucky ones that I would say my remission has been ongoing for years and years now. Don't ask me why. You know, it's interesting.
Jayson:
The old adage of the that at some point the disease burns itself out or, or lessons in severity. That's kind of true. And why I say that is, the reason that's true is because my si joints have fused my lower back is fused. So once the fusing is, is done, that pain is mitigated, that pain is lessened. So that's kind of the the it burns itself out, so to speak, is that it's got nothing left to fuse. And that's where the great amount of pain comes from. So I've tried to tell people that I said, if you can progress through that fusing, if your body progresses through it, the pain can change for you. But there's no set time. It's not like it's gonna be simply you're 20 So by your 40s and 50s, you should be fused and the pain will change. Yeah, you might never be through a fusing, because it might be such a such a slow fuse, that you may never be done with it. Or you could be done in your 30s if it's such a severe onset, or 40s. I mean, there's just no way to set an age timeframe to it.
Michael:
There isn't.
Jayson:
I think that's frustrating to people, they want to know how to control it. And I just got I always tell them, you kind of just have to accept what it is. And if you can, if you can do that for your mental health, that will really help you in dealing with the pain that you're going to continue to encounter.
Michael:
Well, yes, I find it very depressing in many of these Facebook groups, that people are saying, I've just been diagnosed and what's going to happen to me and then the responses that were You've got it, it's a life sentence, it's only going to get worse. That is just so untrue. It's true for some people, but not for some, not for others. I'm a case in point. I went through 10 years of hell before I was diagnosed. The diagnosis for me, was a huge burden off my shoulders. I suddenly understood that this wasn't just in my head, that other people had this disease that there was a name for it. There was a course of disease. There were recommended treatment options. So getting the diagnosis was half the treatment. And I think people who say they've just been diagnosed they're lucky because now they have the diagnosis. So you know, it's something now they can control it or they can start to control it. How do they control it? Well, it's that famous ASIS, the Assessment of Spondyloarthritis International Society, and you lie recommendations for the treatment of axial spondyloarthritis. You have the last slides you have the beam mods including biologics. And in this left hand column here, I'm showing this to you on video. It says education, exercise, physical therapy, rehabilitation, patient associations, self help groups. And to that I would add diet long as any secret diet, but you do have to be careful to make sure you're not eating junk. I mean, that's just common sense. But education is a treatment option that you can take into your own hands. It requires a lifestyle change, as does diet, but you can improve your life by exercising, educating yourself personally, I find that all my years volunteering in this axial spondyloarthritis community has been therapeutic and very educational. So the more you know about the disease, the The better you're able to understand it and cope with it. And then exercise is necessary to stop kytosis, the leaning the bending forward of the neck and to maintain flexibility and range of motion. And then there's recreational exercise that you do for fun. So I'll put a plug in for Walk Your AS Off, which is ongoing during the month of May every year, but it's great. Walking is fantastic exercise. And it's really, really fantastic to see people who couldn't really get off the couch and make it to the front door. You know, through walk your abs off, they've persevered. They've got to the front door, then they've got to the front garden gate. Then they've got to the end of the block, and now they're walking, you know, 5,6,7,10 kilometres a day. It's It's fantastic. It is possible.
Jayson:
Yeah, you don't have to get up and run a marathon your first day. Got you set up if you walk across your apartment or walk across your living room three times, and that's the extent of what you can do. That's great. You know, if you don't have to go and lift heavy weights, if you go to your kitchen and get a big can of tomato sauce, or whatever it is, and pick that up over your head four or five times, and that's the best you can do. That's a start. That's, that's fantastic. It all starts with just committing to moving, move and everything else will fall into place.
Michael:
Yeah, because any activity is better than no activity. And as they say, sitting is the new smoking that applies to everybody. Not just people in our community, but it's true of people in our community. Please, please don't just sit there and feel sorry for yourself. I know it's hard to get over the mental aspect. If you have a significant other, engage that significant other in your quest to Build the better exercise regime and to eat better. They may have to exercise tough love on you, sometimes they wouldn't have survived my 10 really bad years without my wife, you know, kicking me in the backside from time to time and saying, You can't just sit there and stare at a wall all day by cool. You have to do something well, that's my attitude.
Jayson:
That is so true. And, you know, if you're diagnosed now, just having access to something like a biologic, which can allow you to feel better to control that inflammation to get moving. I always tell people, I'd like to take a side picture. Sometimes I'm going to do that. Take a side picture of me standing on my cane, hunched over and say, you know, when you're feeling good about that biologic, you know, you say I've been on it, where I was going with this, the one that drives me nuts is when you see somebody says, Well, I took a biologic for two years, I feel good, so I stopped.
Michael:
Oh, no, that's, that's crazy.
Jayson:
That's not how they work and your doctor should have smacked upside the head for saying that. Yeah, you just having the function or the ability to get on a biologic and control that inflammation? Yes, it's gonna probably be for the rest of your life or for at least the foreseeable future, until something different changes. But take it control that inflammation because the damage that rampid inflammation can do is and that's why I say I'd like to get the picture of me standing hunched over on a cane. This is what uncontrolled inflammation can do to you.
Michael:
Yeah, yeah. No, I understand that and people shouldn't avoid anti inflammatories. If they if they are experiencing a lot of pain. It's necessary to stop that deformity or at least try and slow down the progression of it is something now called, there is an idea now The Treat to Target. It works very well in rheumatoid arthritis because rheumatoid arthritis is much more measurable than Ankylosing Spondylitis is in terms of you know the number of painful joints and stuff like that. So treat to target doesn't really work quite as well in axial spondyloarthritis as it doesn't rheumatoid arthritis, but it's basically setting a goal and the goal is treatment stability. And when somebody is on that stable treatment, whether it's an inside or whether it's biologic, then you can start looking at reducing the dosage. So it has been tested and it does work so people who who aren't biologics can take start can start taking doses at longer intervals or reduced doses section Target is something that's very interesting coming down the line, as is personalized or precision medication. You know, at the moment that anyone biologic only works on about 70% of the patients who are given it. So you find that patients are revolving through the biologics until they find the one that works for them with precision medication, you will be matched up to the biologic that works for you from day one. There's no need to waste a lot of time revolving through these things.
Jayson:
I did an interview a few months ago with a research rheumatologist at the University of Michigan hospital. And that's one of the things that they're working on is the way to go in and identify which biologic will work so that it's not such a crapshoot and say, oh, we're going to move this patient a right to Cosentyx or to Humira or Remicade. Whatever. Yeah, because we've identified and been able to identify that that's what they're gonna, that's what they're going to respond to. So very interesting, very interesting stuff coming down the pipeline and very interesting stuff, though, has been done in the last 30 years.
Michael:
It is and that progresses is ever accelerating. Now we're looking at jak inhibitors and other inhibitors that are given in pill form. You know, you don't need an infusion. You don't need a injection. You just take a pill.
Jayson:
Sounds good to me.
Michael:
Exactly.
Jayson:
So well, Michael, with that said, I really appreciate your time today. And I look forward to interacting more with you online and, we'll see about maybe in six months or so having you back on and we'll see if I can get some other folks we'll get a more robust conversation just on axial spa arthritis and the removal of even the differentiating it further underneath there from radiographic versus non-radiographic.
Michael:
Yeah, absolutely, its been a pleasure talking to you. And there's lots coming down the line, as we've discussed, and we didn't even talk about World AS Day.
Jayson:
No, that will. We'll do that on the next episode in prep for the 2021.
Michael:
Good stuff.
Jayson:
Since we're coming and going real quick on this, but, Michael, thank you again for your time.
Michael:
Jayson, I look forward to talking to you again.
Jayson:
And me talking to you too. I look forward to it.
Michael:
You take care, sir.
Jayson:
Yeah. Thank you. Bye bye.
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