A Call to Arms: Treat Rheumatologic Disorders Early and Effectively with Disease-modifying Therapy

Musings


Stephen A. Paget, MD, FACP, FACR

Physician-in-Chief Emeritus, Hospital for Special Surgery

Most rheumatologists would agree that early, appropriate therapy is mandatory and necessary for an optimal outcome in nearly every one of our disorders. However, despite the fact that excellent evidence supports the use of disease-modifying treatments, we still see many patients with osteoporosis, rheumatoid arthritis, systemic lupus erythematosus, and gout who are not optimally treated in a timely manner. Respectively, our disease-modifying armamentarium for these disorders includes bisphosphonates, DMARDs, hydroxychloroquine-steroids-cyclophosphamide, and allopurinol. So, why does this happen?

Sub-optimal Physician Education and Too Few Rheumatologists. Ninety percent of patients with musculoskeletal (MS) and autoimmune (AI) disorders are receiving their "rheumatology care" from their primary care physician of one stripe or another. While none of these physicians would ever let their mother or father be treated for an MS or AI disorder by anything but a board-certified rheumatologist, their patients are often treated in this way because of various "realities" in our present medical system. Because medical school and house staff training in recognition, diagnosis and treatment of such disorders is so poor, is it a surprise that well-intentioned physicians on the front line either miss or mistreat these diagnoses/patients altogether because they don't even know what they don't know?

This is the first call to arms: the training of medical students and house officers must improve because one in six patients present to their primary care doctor for assessment of an MS disorder. The educational responsibility is in every rheumatologist's hand, particularly those in teaching hospitals. If this does not happen, the ones who will suffer will not only be the public at large but also our family members and us in the future. Locally, we need to lobby our medical school deans and chairs of the departments of medicine to assure that when students/residents complete their training, they are well versed in the recognition and treatment of rheumatologic disorders. Innovative teaching programs for all levels of education -- from medical student to fellow -- are available via the American College of Rheumatology (ACR) and should be disseminated throughout the country's medical centers. Continuing education programs are also key, not only to solidify and update previous educational experiences, but also to teach new information.

The subspecialty of rheumatology is the smallest in the field of internal medicine, and it is clear that, as the population is aging, more rheumatologists are needed, not fewer. However, the predictions are that the field of rheumatology will continue to shrink unless drastic actions are taken by organizations like the ACR. A career in rheumatology continues to be an extraordinary one intellectually, and we must stimulate physicians in training to consider it.

Late and inadequate treatment. Even when we have effective and well-tolerated medications for MS and AI problems, at times we do not employ them optimally. This applies to both the primary care physician and the rheumatologist, but more the former than the latter.

The presentations of and treatments for MS and AI disorders are not generally well- appreciated by primary care physicians. That relates to the often inadequate education in medical school and training, as well as to the mass of new medical information that they must absorb. Each MS and AI disorder has its "window of opportunity" for optimal outcome and minimizing tissue damage and dysfunction. Thus a late diagnosis (meaning many months or years after the onset of characteristic symptoms) of rheumatoid arthritis or lupus, for example, could leave a patient with irreparable joint or kidney damage, simply because therapy was not instituted in a timely manner.

Some examples might be helpful. It is generally accepted that bisphosphonates "alter the natural history of osteoporosis" and yet fewer than 25% of elderly patients who sustain a fragility hip fracture are treated with bisphosphonates such as alendronate (Fosamax) and residronate (Actonel). With rheumatoid arthritis (RA), it often takes many months or even years for the diagnosis to be made and, even when it is made, treatment is often delayed or inappropriate. This is particularly disturbing given the extraordinary disease-modifying advances that have been made with this disorder. In this day and age, just as no physician would hold back treatment for an infection, hypertension, angina, peptic ulcer disease or diabetes, neither should they put off early aggressive RA therapy with disease modifying anti-rheumatic drugs (DMARDs.) These drugs have been shown to profoundly decrease the development of joint erosions, joint space narrowing, and functional limitation, and they also lengthen the life span of RA patients. The cytokine burden of untreated RA will also promote the development of premature atherosclerosis and osteoporosis, unappreciated areas of collateral damage. Even some rheumatologists still treat well-defined RA with NSAIDs alone, an antiquated concept for most of the world's rheumatology community. If you think that osteoporosis and rheumatoid arthritis are under-treated, the problem is even worse when it comes to systemic lupus erythematosus, an often complex, difficult to diagnose, invisible disorder that is commonly allowed to smolder for years before it is diagnosed and optimally treated. During this "window of dis-opportunity," organ damage might already have occurred -- damage that could have been averted by the timely institution of steroids, anti-malarial drugs, or immunosuppressive agents. The treatment of severe and tophaceous gout is also mishandled by many physicians, despite the presence of our first true disease-modifying drug, allopurinol (Zyloprim).

The solutions. So, what is the answer to these perplexing problems? First, disseminate information about these disorders to physicians at large, in all fields of medicine and at every stage of their development, from medical school to the practicing physician. Second, primary care physicians should develop close, collaborative partnerships with rheumatologists. And finally, patients need to be informed consumers of medical care, via all forms of modern communication and interact closely with their physicians.


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