War On RA - Part 2 Save

The war on RA part two. It's all about you. This episode is devoted to rheumatologists. In fact, it's a direct mail message to rheumatologists. Those of you who are not rheumatologists can listen in if you like.

Rheumatologists are amazing at how we diagnose and manage such a complex disorder such as rheumatoid arthritis. They live and breathe the mantra of diagnose early treat aggressively. When you look at data from clinical trials about the physician global assessment, it performs almost as well as all other measures in predicting activity and progression. We have tremendous joint exam skills. You know, when I'm doing a joint exam and using my fingers, I'm doing a three d reconstruction of the synovitis in that joint.

And we're very good at it, only to be outdone by MRIs and ultrasounds, are which expensive, not easily attained, and actually don't make, any difference with regard to predicting outcomes and are not a part of any outcome measure. So our exams are quite amazing. We have new tools all the time, we have to evaluate as to whether they're useful. The search for an elusive biomarker isn't quite there yet. Know, it turns out that rheumatologists, it's over like fifty four percent that measure something.

I think ten to fourteen percent do a Vectra. Vectra is not a biomarker. If you think it is, you're sadly mistaken. They haven't done the biomarker studies that need to validate that. And if you need Vectra to manage Rheumatoid arthritis, then you don't know rheumatoid arthritis.

We're doing a really good job of it with or without lab tests. It's really a clinical disease with clinical outcomes that we must make our decisions based on. But I'm here to tell you that again, there's a war on RA and you need to be a part of it. If we're doing such a great job of managing RA, then why do we need a war on RA? Why am I laying this conflict at the feet of the soldiers of rheumatologists who are toiling every day to win the therapeutic battles for their patients?

The reasons are quite simple and quite blunt. There's the sixtyfortytwenty, the ACR20fiftyseventy responses, which are not good enough. We have eighty percent of patients in clinical trials who do not achieve remission and know you don't do much better in clinical practice. We have RA patients that have a very high mortality rate, much higher than the general population and it's largely driven by inflammation and pain and what that gets you. RA is not going to get better by itself.

All the challenges that we're talking about are anchored and go through you, the rheumatologist. You're part of the daily battles and part of the future victories that are needed. If you're not going to do it, then who will? We scoreboard our successes in many different ways. We often point to the hallmark achievements in therapeutics with different eras.

1900, the aspirin era, nineteen fifty's, the steroid era, 1984, the methotrexate era, and 1990s, the biologic, or not the biologic, the combination era, and then 2,000 or so, the biologic era. We have two JAK inhibitors on the market now, maybe a third or a fourth by the end of the year. Will this take us to a new level in outcomes? Will we again rely on therapeutics to get us there? I'm saying not.

Certainly, Ari has gotten better and you're a part of that success. These therapies are a part of that success. And this is very clear when you look at radiographic progression rates, are much, much less now than they were in the 1980s. Erosive score is much much less. Arthroplasty rates have plummeted.

If you look at TJC, SJC counts in clinical trials and HACS scores patients are better decade by decade. All largely benefiting from an earlier diagnosis and the earlier institution of DMARN therapy. It's really less clear, however, whether other improvements have been seen in referral times, pain scores, comorbidities, and survival statistics. There are a lot of reasons that I think that we should rejoice and maybe some of them are tempered by some of the contrarian facts. So the reasons we should rejoice, we're better rheumatologists.

We've got more experience, more tools, and better drugs to play with. Yet, we're still only achieving remission rates of twenty to thirty percent and that's being generous. When I ask rheumatologists how often do you achieve a remission in your practice? You say sixty percent of the time. Well, that's sort of crank head, crazy talk if you ask me, because it's not backed up by any data.

It's backed up by your impressions and you're not doing measurements like, people would need to do to come up with statistics like that. But nonetheless, have better drugs. We have really enjoyed a bull market with surges in therapeutics at different points in the last twenty years. But even though we have many new drugs, many of them are copycats. Of the current 19 biologics that have been approved in the last twenty years, 15 of these are copycats or biosimilars.

We have two JAKs and again, maybe have three or four by the end of the year. You can't always believe the lion eyes of a shiny new drug when it comes along. We have better guidelines, algorithms and plans, but yet you're not really adhering to them saying that's for other people who don't know what they're doing and that you're sort of basing it on experience and what you can get away with based on what insurance will let you get away with. Nonetheless, you shun evidence based medicine in many instances, and you are managing flares with our most dangerous drugs, corticosteroids. That's a little, I think in conflict.

We have better patients. Our patients are better informed. They're more inquisitive. They're certainly more involved, but all is not well with our patients. We have horrible non adherence rates.

They, ninety percent or more of my patients show up solo at their visits for this horribly complex and disabling disease. Where's the husband? Where's the spouse? Where's the friend? Where's the sister?

I don't know. Even more quizzical is the equipoise between the words that I give them and the words that they hear from the Internet friends and their hairdresser. Sort of drives me crazy. I know it drives you crazy. Crazy.

I think some of the problem here is that we've gotten too good. Life in the fast lane has become easy street in RA management. We've grown accustomed to writing doing good in the chart of a patient who will progress in front of you and on paper in the years to come. Patients are stable and that's a great outcome, but it sublimates any ideal quest for remission and maybe that's where we have to go and have to demand. The question is what can you, the rheumatologist do if you want to win the war on RA?

Number one, like all wars, you must win all the battles, especially the important ones. And I would say those are early RA, erosive RA, preclinical RA. You can decide on your own most important battle. Number two, you got to change your standards. If you don't change you and the way you practice, you're going to keep getting more of what you got.

Higher standards for the clinic, higher standards for drug management, for outcome assessments. You know, everyone's interested in early RA diagnosis, but nobody does anything about it. It's like the weather, meaning you're not going out and recruiting those patients. You're kind of waiting for them to show up in your clinic. Most of us do not have an early RA clinic.

Most of us do nothing to facilitate early RA and inflammatory arthritis referral. Number three, mandate that all RA patients be treated by rheumatologist. Even better if we were all diagnosed by a rheumatologist, we'd be there from the very start. That's not happening. All the statistics show somewhere between thirty, forty four and forty eight percent of all RA patients are in the hands of rheumatologists.

It's really quite disappointing because you know what happens when they're managed by other individuals. You know, cohort studies show that, you know, less than fifty percent are all patients in claims data are on a DMARD within the first year. It's higher when those patients were being managed by a rheumatologist goes up from forty four to sixty eight percent. And there is even better data from the ACR Rise Registry that says that ninety one percent of all rheumatoid at their last visit declared that they were taking a DMARD. So yes, it needs to be in the hands of rheumatologists.

We should demand it. Fill up all our spots with RA and less with things that are not going to get better and things that we probably shouldn't be seeing like osteoarthritis and fibromyalgia. Number four, stop waiting for RA to appear on your doorstep. Yes, it's about early RA, but again, you're not going to get all the patients unless you go out and market them. They're in the hands of primary care.

You need to market yourself as the expert, as the person who has a career commitment to managing this complex disease. There are lot of other things you can do. Number five, getting involved in research, trials, translational work, bio banks and registries. I think that many of us think that the next great discovery is going to come from some other discipline in medicine and science when in fact it's likely to come from an innovator, translational worker taking, advantage of a new system of data information in advance and applying it, to better understand a very complex disease. It might also come from big data, artificial intelligence, predictive analytics, all of which you can be a part of being one of a thousand clinicians who provides data to this gigantic effort.

If an effort like that gave me a ten, fifteen, 20% advantage on who's going to respond to what biologic, why shouldn't we do it? Wouldn't that be a great advance? Number six, get involved locally, have think tanks and group sessions where you can share your input, with others and get the collective insight of many and the experience of many to work towards some difficult problems in RA care. But lastly, and most importantly, you have to change yourself. If you, again, if you keep thinking that you're doing great without changing yourself, then things are not going to get any different.

This is all about you changing you. Most of us don't like to talk about T2T because we mostly measure but we do nothing about it. We think we're doing T2T but we're not measuring. It's confused but it's really not happening. The original study on treat to target was the Grigor study which actually took old drugs, sulfasalazine, hydroxychloroquine, methotrexate, and gave them to patients in one or two regimens, usual regimen and the T2T regimen, and those who are on T2T or intensive therapy at a fourfold higher outcome, sixteen percent to seventy percent remission rates or ACR 70 rates based on what you did as far as how you behave and manage the patient.

Nothing to do with the drugs, had everything to do with the way you manage the way you treat the patient. Gandhi said, be the change you wish to see in this world. I think what's lacking in RA care is urgency. I think we have to recognize that adversity can breed ingenuity, excellence, and goodwill for many. If you recognize and believe that there is adversity, that this is an adverse situation that we are managing, then there's a chance that you could make a difference.

We're managing this well enough. We're winning, the battles, but again, not well enough to win the war. I said it before, I'll say it again. If you keep doing what you're doing, you're gonna keep getting what you've got. That's it for the War on RA.

This is the second in a four part series on the knee challenge and tactics needed to win the War on RA. Your input, suggestions, and pleas are needed to move forward on this. Tune in next week for another episode of the War on RA.