When should you see a rheumatologist?

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By Dr Irwin Lim, Rheumatologist

I know this is a bit of self promotion but I really do think that as a group, rheumatologists, are best placed to treat patients with arthritis and a range of musculoskeletal disease.

We listen, we examine, we try to put the clues together. We then work with a team of other health professionals to develop a solution to help the problem.

As a craft group, our profile is poor so I am always happy to see steps in improving this.

This is a video created by the American College of Rheumatology. I hope you like and share it:

 

 
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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Can we use biologic DMARDs early then take them away?

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injection devicesBy Dr Irwin Lim, Rheumatologist

Another one’s here!

I recently wrote about a strategy trial using Etanercept very early in the treatment of rheumatoid arthritis followed by withdrawal of the drug (Read “Can we use TNF inhibitors early then take them away?“).

This was a much anticipated trial providing insights which will help us use biologic DMARDs more strategically.

Well, we now have another similar strategy trial published.

This time using a biologic DMARD with a different mode of action, Abatacept. Abatacept is a fusion protein of cytotoxic T lymphocyte-associated antigen-4 and immunoglobulin G1. It selectively modulates a signal required for full T-cell activation  (Etanercept by way of comparison, is a TNF inhibitor).

Here is the link to the journal article: the AVERT study.

As a brief summary:

  • The patients recruited had early disease (a mean symptom duration of 0.56 years). They had a high inflammatory burden (a mean swollen joint count of 11.1 and a mean CRP of 17.5 mg/L), as well as poor prognostic factors (all had positive anti-CCP with 95% also having a positive RF).
  • Patients were randomised to Abatacept /Methotrexate (MTX)  in combination vs Abatacept alone vs MTX alone.
  • At month 12, the proportion of patients in these 3 groups achieving DAS28<2.6 (Disease activity score-defined remission) were 60.9% vs 42.5% vs 45.2%.
  • These patients who achieved DAS28 remission then had their treatment stopped rapidly! Abatacept was withdrawn immediately and MTX (as well as any corticosteroids used) tapered over 1 month.
  • At month 18, 6 months after withdrawal of therapy, 24.7% vs 28% vs 17% remained in DAS-defined remission.

These are encouraging results given the group of patients would be considered “difficult” as they had highly active disease at baseline with poor prognostic factors.

A durable remission following withdrawal of medication remains a holy grail in early rheumatoid arthritis. This trial seems another nice step towards this.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Slowing Down a Speedy Rheumatologist

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By Dr Irwin Lim, Rheumatologist

My brother and wife introduced me to Audible and I’ve become a little addicted to this audiobook service. I find I can listen while driving and listen while I’m on the exercise bike so I no longer neglect “reading” books.

I recently completed the 7 Habits of Effective People by Steven Covey.

There was clear room for me to improve and the major message I took from this, is one our staff at BJC Health will no doubt agree with.

You may find this hard to believe (ahem..) but I’m a little impatient and very quick-to-the-point.

I know this is a weakness and one I want to correct. But it’s so, so hard.

Counting to 8 before I speak is a skill I certainly do not have……..

The 2 things I learned and had reinforced which I will improve are:
  1. Trying to listen twice as much as I speak.
    • This will help me understand the other person’s point of view, and prevent me from launching into my own point of view. If I can make the other person feel that I have listened to them, and if I can truly understand their position, we are likely to be able to work on a win-win solution.
  2. Slowing down.
    • I pride myself on efficiency and that’s probably a useful thing when juggling the demands of the clinic and life. Efficiency is great with processes but it’s not so good with people. Stuff with people works better slow. Working with people and their belief systems take time. Making collaborative decisions is not usually a quick process.

So these are going to be my New Year resolutions.

I’d like to be a more effective doctor and a more effective person.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Giant Cell Arteritis: a rheumatological emergency

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By Dr Irwin Lim, Rheumatologist

In rheumatology, there are few super-urgent, “life or death” situations. I like it that way.

Most times when urgency is involved, it’s usually relates to a severe side effect or to a severe infection. Rarely, it relates to the manifestations of difficult disease processes, such as vasculitis (where there is inflammation of blood vessels causing a lack of blood supply to the organs the vessel supplies).

Last week, I took an urgent call from a local GP. She’s a very astute GP and when faced with this older gentleman presenting with headaches, fever, a feeling of being unwell as well as a lot of tenderness at his right scalp, she immediately suspected this relatively rare disease.

Temporal Arteritis

Temporal Arteritis

 

Giant Cell Arteritis (read more about GCA here).

This is an emergency situation and should be treated as such.

Giant Cell Arteritis can lead to sudden, permanent loss of vision and prompt treatment can prevent it.

We discussed his case over the phone and these were organised urgently:

  • A same-day appointment with an Ophthalmologist to examine the eyes and to arrange biopsy of that very swollen, painful temporal artery -> the diagnosis was confirmed with classic pathological changes on the biopsy.
  • Immediate commencement of high dose Prednisone -> He was given 75mg daily of Prednisone and his symptoms improved dramatically over the next few days.
  • Measurement of inflammatory markers -> the blood tests did show markedly elevated ESR and CRP, blood proteins which increase in this disease due to the vasculitis.

What about my role as a rheumatologist?

Well, the good news with this disease is that the use of corticosteroid, Prednisone, helps immensely. The problem is that the antidote is Prednisone. I’ve already written about the 2-edged sword that Prednisone can be (here’s a link to posts re corticosteroid). And this is definitely the case at these higher doses.

So, in this disease, the rheumatology management consists of:

  • Managing the gradual reduction/taper of the dose of Prednisone. Steroid reduction can be difficult. Many rheumatologists, including myself, use Methotrexate to help with this steroid taper. Methotrexate acts as a “steroid-sparing” agent.
  • Predicting and trying to limit or avoid the side effects of Prednisone, for example:
    • Checking the bone density and then trying to prevent steroid-induced osteoporosis/bone loss.
    • Anticipating the weight gain and effects on metabolic syndrome and instituting measures to try and help. Attention to diet and nutrition is important as well as exercise.
    • Anticipating the weakness of the proximal muscles (thighs, upper arms) and instituting appropriate maintenance and strengthening exercise.

All this needs to be done, while trying not to reduce Prednisone too quickly to avoid a flare in the disease, as a lack of control on the inflammation causes many unwanted symptoms, and in particular, increases that risk of sudden blindness.

Have you any experience of this condition?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Can we use TNF inhibitors early then take them away?

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By Dr Irwin Lim, Rheumatologist

I think that increasingly rheumatologists would like to be able to use TNF inhibitor medications much earlier in the course of rheumatoid arthritis (RA).

These drugs are effective in RA and the hope would be that earlier use leads to higher rates of remission, lower rates of joint damage, and ultimately better long term outcomes.

There are some patients who come into my room with quite severe arthritis at presentation and the goal is clearly to get disease control as soon as possible.

Understandably, early use of these agents in many countries, including Australia, is not government funded. This is due to their high cost and the argument is that we, the taxpayers, just can’t afford it.

What may change this?

Well, we have been waiting for clinical trials to give us insights into strategic use of these medications.

In the November 6th issue of the New England Journal of Medicine, such a trial has been published (read the abstract here).

This 3-phase trial tried to test the value of using Etanercept/Methotrexate in combination in patients with early RA (“early” in this case, meaning those with onset of symptoms within 12 months of enrolment) and then taking away the medication.

306 patients from multiple different centres in Europe and Asia were enrolled. The design was as follows:

  1. Phase 1: treat early RA with weekly 50mg Etanercept plus weekly oral Methotrexate (MTX) for a total of 52 weeks.
  2. Phase 2: those who achieved low disease activity at week 39 and remission at week 52 were then randomised to one of 3 groups. These 3 groups were:
    1. half-dose Etanercept at 25mg weekly plus MTX, or
    2. MTX alone, or
    3. Placebo treatment only.
  3. Phase 3: At week 39 after randomisation into the phase 2 groups, all those who continued to have a good response were taken off all medications and followed up to week 65 (post-randomisation).
Accessed from NEJM App 6 Nov 14

Accessed from NEJM App 6 Nov 14

 

A complicated trial. Trying to answer some important questions.

I’m sure it will be analysed and debated by the experts in detail but the initial take-home messages are:

  • A high percentage of patients in phase 1 reached remission (70%) according to DAS28 criteria.
  • In the step-down therapy phase, phase 2,
    • 40 (63%) of 63 patients in the half-dose etanercept plus MTX group vs 26 (40%) of 65 patients in the MTX-only group vs 15 (23%) of 65 patients in the placebo group achieved DAS28 remission at weeks 24 and 39.
  • Of the patients who continued to have low disease activity who entered phase 3, and who had all their active medication stopped,
    • 44% of the phase 2 combination group continued to be in DAS28 remission at week 65 after randomisation vs 29% of the MTX-only group, vs 23% of the placebo group.
  • There were not any significant changes in the progression of damage on Xrays
Accessed from NEJM App on 6 Nov 14

Accessed from NEJM App on 6 Nov 14

 

So, this trial seems to provide evidence that once we achieve remission in an early group of rheumatoid patients using combination Etanercept/MTX therapy, we are then able to reduce and even withdraw the TNF inhibitor. In some, we can even withdraw MTX.

We still don’t know how to pick which patients will be able to have their medications stopped without the disease flaring.

So, in practice, rheumatologists will just taper therapy cautiously, monitor patients carefully, and restart treatment upon flare.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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