Physician's Weekly Article - Tightening Control of Rheumatoid Arthritis

       Many patients with rheumatoid arthritis still suffer from symptoms despite years of therapy on medications. What can physicians do to better serve this patient group?

      About one of every 100 Americans suffer from rheumatoid arthritis (RA), a progressive autoimmune disease that destroys joints over time. The disease can occur at any age and commonly affects the wrists, fingers, knees, feet, and ankles. The course and severity of illness can vary considerably, and it is believed that genetic and environmental factors determine its occurrence and severity. “In RA, inflammation causes pain and stiffness,” explains Philip J. Mease, MD, “and the gradual destruction of joints leads to functional disability.”

      Chronic pain, stiffness, and disability are all key issues surrounding RA, but Dr. Mease adds that physicians should also recognize that patients with the disease die approximately 7 to 10 years earlier than healthy individuals on average. “The increased mortality rate associated with RA is primarily due to inflammation-induced atherogenesis,” he says. “In chronic inflammatory diseases such as RA, increased amounts of plaque build up in the critical arteries of the heart and brain, leading to atherosclerosis. This results in an increased risk of heart attack and stroke. In addition, patients with RA have a greater proclivity toward certain cancers (eg, lymphoma), infection, and osteoporosis, which can further increase patients’ risk of premature death. Fortunately, the advent of more effective biologic therapies is improving our ability to control the disease and its consequences for many sufferers.”

      Analyzing the Doctor-Patient Disconnect

      A recent Harris Interactive Survey found that many patients with RA have been on prescription therapies for years and switch treatments frequently, but still struggle to control their symptoms (Table 1). “Some physicians who treat patients with RA aren’t prescribing newer biologic agents that can better control symptoms or are not managing the new agents effectively because it is outside of their comfort zone,” Dr. Mease says. “Providers are relying heavily on oral medications to treat RA, but these agents often only partially relieve symptoms. The newer biologic therapies offer advantages because they can more effectively inhibit progression of joint destruction. While these therapies carry potential risks and can be costly, they’re more effective, and their benefits can greatly outweigh risks when prescribed appropriately.”

      Another key finding from the Harris Interactive Survey was that many RA patients have lower expectations of treatment (Table 2). “Patients often just accept the pain, stiffness, and disability associated with RA because they’ve lived with it for so long,” Dr. Mease says. “Many won’t ask their physicians about changing therapy because they don’t want to be viewed as complainers. There is also a real disconnect in what patients believe they’re conveying to their physicians and what their physicians are actually acknowledging. Some physicians aren’t paying attention to complaints of more severe pain and discomfort. A greater effort on the part of physicians is needed to better appreciate the progression of symptoms so that more effective treatments can be provided.”

      Close Gaps With Tight Control

      Dr. Mease says that it is critical for physicians to understand that early, aggressive treatment of RA can make a big difference. “Physicians need to triage patients and refer them to specialists if they aren’t experiencing improvements in symptoms after introductory therapies. For example, non-steroidal anti-inflammatory agents have been used for lengthy periods of time. We’re now armed with newer medicines that can better control inflammation; we have the capability to improve quality of life and comfort more quickly. Perhaps more importantly, these agents can reduce the risk of long-term disability and premature death. Furthermore, we should empower patients by fostering open communication so that they’ll discuss their condition with physicians. Steering them to educational resources such as the Arthritis Foundation can help them think more clearly and critically about their symptoms, which in turn makes them become more vocal with caregivers.”

      An emerging concept in managing RA, according to Dr. Mease, is to achieve “tight control” of the disease. “Achieving tight control of diabetes and hypertension, for example, has been proven to improve health outcomes in these disease states. The same is being shown in RA; more aggressive treatment can increase the chance of achieving low disease state or remission and is associated with lower rates of destructive changes in the joints. With the newer biologics now available for RA, physicians have a better chance of achieving tight control of RA. If patients aren’t fully responding to their first prescribed biologic agent or if they’re losing response over time, we need to consider switching therapies or using a newer agent that has a different mechanism of action. To best assess response, we should be quantitatively measuring disease activity with one of the composite joint count measures such as the Disease Activity Score-28 and patient-reported measures such as the Health Assessment Questionnaire, or HAQ, to monitor patients and improve our understanding of how they’re doing. The smorgasbord of emerging treatment options gives us a better opportunity to achieve tight control.”

      Philip J. Mease, MD has indicated to Physician’s Weekly that he has received grants/research aid, worked as a consultant, and has received speaking honoraria for Abbott, Amgen, Biogen-Idec, Bristol Myers, Centocor, Genentech, Merck, Pfizer, and Wyeth. He has also consulted for Roche and UCB Pharma.