Tuesday, 15 Oct 2019

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War on RA - Part 1: Walk on the Moon

It’s a great time to be a rheumatologist.

In this era, with decades of productive research and novel insights, the outcomes in rheumatoid arthritis (RA) have steadily improved by nearly all measures – functional (HAQ), death rates (declining), arthroplasties (down), etc. We have many in trenches fighting to improve the lives of RA patients.

RA can be a devastating diagnosis.  I have to encourage my RA patients by telling them that battle against RA is being fought every day by many who are toiling to advance the science and treatment options or to develop a cure.  Moreover, there are seemingly limitless funding sources to fuel these efforts. 

It’s a grand thing to have so many options, approaches and insights that can benefit the RA patient. It is rare, rare, rare that I don’t have another option for the next patient I see with uncontrolled RA.

Rheumatologists are amazing in how adroitly they can assess and manage the complex immunologic mess that is RA.  Great knowledge, great skills, an expanding arsenal of effective therapies is what the rheumatologist brings to bear every day in the clinic.

But it’s time to realize that no matter how strong your beliefs are about RA, there are many truths which can be disheartening and can tell a different tale of RA. These killer truths include:

  • RA is a progressive and destructive disorder (in everyone)
  • RA is a deadly disease: the average patient dies at age 67 yrs., nearly 10 yrs. younger than they should have
  • The diagnosis is still delayed in too many; RA is seldom recognized clinically and only given serious consideration when PCP lab testing suggests RA
  • The toll exacted by RA, the disease, on the person, the family, and society is devastating in too,  too many.

Rheumatologists are very happy about our therapeutic progress since 1984 and the introduction of methotrexate.  We are happily driven by our patient’s successes and recant the great victories in RA patient care.  

Our successes are easily remembered, but we don’t really talk about our failures - the severity, risks, mortality and bad outcomes of RA.  Zig Ziglar said that “..failure is an event, not a person”, and certainly not a disease.  Its important to remember we must fail many times to increase our chances at real success.

We are perplexed with “difficult RA” patients who don’t seem to respond to anything; accepting that there are such patients because we done truly understand all RA. Sometimes poor outcomes are attributable to disconnected healthcare, complications or comorbidities.

As we manage RA in 2019, we will have many successes, win many battles, and deal with the casualties of war - but we will never win the war unless there is a push to do. 

RA is not war that we are not currently winning and may not be appropriately fightly. We we won’t win this war until we meet the challenge in many new concerted and collaborative ways.  

I know, I know; this is deep dark stuff to discuss and even harder to align with when we believe we are doing so well in RA care. 

My response is – “if you keep doing what you’re doing, you’re going to keep getting what you’ve got.”  You should quote me on this.

Do we need a war on RA?  

In 1962, President John F. Kennedy said:

“We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.”

With public support, government funding and a concerted effort, in we landed on the moon in 1969.

We are currently stuck with earthly, predictable 60-40-20 ACR responses to our best new therapies in RA.

A similar moderate ceiling effect in response (PASI75) was seen in dermatology and psoriasis for many years, until  the targeting IL-23 and IL-17. With their introduction, the ceiling was raised from PASI75 to PASI100 (total clearing). 

In our medical lifetime, we have seen other amazing conquests over difficult diseases, including non-Hodgkin’s lymphoma (NHL), hepatitis C infection (HCV), and HIV. Even bleak disorders like malignant melanoma and pancreatic cancer have slowly but steadily been moving the needle on survival in the last decade. 

But no one gets mad about RA – except me and you.  Most of the unknowing populace believes that RA is a lifestyle disease.  We know better, we have a front row seat in the battle against this devastating disease.

Not until there is a critical mass of people willing to go to war against RA, will this movement or research surge, or paradigm shifts change the tide of this campaign. Rheumatologists need to wave this flag and ignite the war so that many more will sign on – more rheumatologists, researchers, drug developers, public policy makers and more. We need breakthroughs, more than biosimilars and me-too drugs and a focus on the enemy.

Ulysses S. Grant quote on war:

“The art of war is simple enough. Find out where your enemy is. Get at him as soon as you can. Strike him as hard as you can, and keep moving on.”

We know who the enemy is.

We’ve already ascribe to the belief “diagnose early, treat aggressively”.

It’s time to “move on”, in new ways, so we can turn RA outcomes into those achieved in HCV, NHL and walking on the moon.

This is a challenge we cannot postpone. It must be one we intend to win.

 

This is is the first in a four part series outlining the need, challenge and tactics needed to win the war on rheumatoid arthritis. Your comments, suggestions, pleas and enlistment is passionately needed!

Read War on RA - Part 2: It's All About You

Read War on RA - Part 3: Useless Drugs

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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