Rheumatoid: You must stop smoking!
Image courtesy of scottchan / FreeDigitalPhotos.net
By Dr Irwin Lim, Rheumatologist
I was discussing rheumatoid arthritis management with a bunch of colleagues, and we were discussing various peculiarities and relative properties of the biologic medications.
At some stage, one rheumatologist mentioned that she finds herself spending more and more time addressing smoking cessation.
Patients with Rheumatoid Arthritis die from heart attacks and vascular complications.
This is well known, and the good news is that better disease control reduces the risk of this. In addition, TNF inhibitor therapy reduces this risk of dying from cardiovascular causes more than the traditional DMARDs.
But we can do more. Weight loss and improved nutrition, increased exercise to improve fitness, treating blood pressure, et cetera.
Often, the hardest nut to crack is SMOKING.
Smoking is not good for Rheumatoid because:
- It acts as a trigger leading to the disease
- It leads to more active disease
- It reduces the effectiveness of Methotrexate
- It reduces the effectiveness of TNF-inhibitor therapy
And by the way, if you didn’t already know, smoking does cause lung damage, increases risk of cancer, and greatly increases the risk of strokes and heart attacks.
I remarked to this very caring and competent rheumatologist that I wasn’t very good at getting my patients to stop smoking.
If you’re a smoker, what can I say to you to make you stop? Because, you really do need to.
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.Vidscriptions on Rheumatoid Arthritis: The Basics
By Dr Irwin Lim, Rheumatologist
I managed to get some time last weekend to record these videos on Rheumatoid Arthritis. Thanks to my patient wife for helping film using my iPhone 5 and a green screen, microphone & tripod set-up courtesy of clear.md.
Visit www.clear.md to search health topics and watch short, single-topic videos by doctors.
For our clinic, I’m attempting to record series of short videos answering what we believe will be common questions patients will have.
After receiving a diagnosis or during important time points in the disease management, for example, when we are discussing significant new medications, our rheumatology care coordinator will email patients links to these vidscriptions.
We don’t plan for these to replace the discussion & education that takes place face-to-face, but these vidscriptions will reiterate and remind.
What do you think?
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.Maybe what my Rheumatoid patient reports is more useful than my tests?
By Dr Irwin Lim, Rheumatology
I listened to Theodore Pincus speak on the weekend. I found the professor of rheumatology very entertaining and his ideas made an impression.
The clinical approach to rheumatoid arthritis is very different from the approach to typical chronic diseases such as hypertension or diabetes.
With hypertension, there is a simple gold standard of blood pressure. With diabetes, it’s measuring the HbA1C. Patient history and physical examination don’t play a big role, and what the doctor decides to do is typically based on the gold standard measure.
With rheumatoid, there is no laboratory test or any other measure that can serve as a gold standard. Blood tests can be normal in the face of significant disease. Clinical examination can be variable and deciding which joint is swollen or tender is not a consistently easy thing to do. Our job is difficult!
Because of this, composite disease indexes have been developed to help us rheumatologists make our clinical decisions. The most widely used, and the one I use, is the DAS 28. This Disease Activity Score takes into account measures from a physical examination, laboratory tests and a patient self-report of how much the arthritis affects them.
Composite measurements like the DAS28 are not perfect ( as discussed here by Dr Philip Gardiner) and the DAS28 is used by only a minority of rheumatologists in Australia (probably the same worldwide). Often, the failings of the measure are given as reasons why it’s not used by those who choose to rely on “clinical” judgement. But, I think a perception that it takes a lot of time and a lack of exposure to using it in rheumatology training play a big part.
Professor Pincus developed the RAPID3 (Routine Assessment of Patient Index Data 3).
This measure includes only 3 patient self-report measures. It should take the patient less than a minute to complete and can be scored by the rheumatologist in less than 10 seconds!
This makes me very excited. I profess that I’ve previously heard about the RAPID3 but never really bothered investigating it further.
In rheumatoid, what the patient says is important and should feature prominently in management decisions, especially as we don’t have great “objective”, “scientific”, gold-standard measures.
The RAPID3 seems very simple, almost too simple but it’s been shown to correlate significantly with the DAS28. And that’s without formal joint counts or blood tests.
Professor Pincus made the point that patient questionnaires (like RAPID3) and scores of function actually predict mortality better than joint scores, laboratory tests and Xray changes! They also better predict long-term outcomes such as work disability, joint replacement surgery, functional status.
Now, I’m not likely to stop examining my patients and I’m sure I will still be ordering blood tests and imaging tests. And of course, patient questionnaires like RAPID3 have their own limitations.
But, it would seem to make sense for my patients to self complete this rather simple RAPID3 form before they come into my room.
It provides another piece of information to document how a patient is going, in a quantitative way, to compare from one visit to another. A measurement. A sort of rheumatology-blood-pressure substitute.
Have you had any experience with the RAPID3? If you have rheumatoid, do you think it’s worth filling?
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.The Goal Posts for Rheumatoid have moved
By Dr Irwin Lim, Rheumatologist
Once a month, the local rheumatologists meet at our tertiary level, teaching hospital to discuss challenging cases. We invite the patients being discussed to attend. Usually, there’s a question being asked, a problem to resolve or sometimes, it’s just cathartic for the patient and treating rheumatologist to efficiently get a range of opinions.
It was my turn.
My patient presented when she was 30 with an abrupt onset of rheumatoid arthritis. More than 20 joints swollen and inflamed, high inflammatory markers, very high autoantibody levels (both RF and anti-CCP). She was struggling to cope with daily life.
Bad disease. By any definition.
Over 6 years, I treated her with a variety of medications: Methotrexate, Prednisone, intra-articular steroid, Arava. Within 10 months of her symptoms, she was on biologic DMARD therapy. She has trialed Humira, Actemra, Orencia, Enbrel, and is now on Mabthera.
She has responded and is of course better than when she presented. But she has never entered sustained remission.
It’s hard to tell that she has rheumatoid when you meet her.
She doesn’t have the classical hand deformity. Her MRI of the hands do not show any active disease or erosive change affecting the fingers.
When you feel the swelling at both her wrists, see her wince a little, and note that she has lost a lot of movement at these joints, you then understand that the disease has caused damage and it’s still affecting everything she does.
I presented her to see if the others could think of anything else to improve the situation.
Among the 6 rheumatologists present, there was over 100 years of clinical experience.
The consensus was that we had done well. A patient presenting the way she did, would in a previous era, be riddled with arthritis and deformity by now. She would very likely not still be working full time.
That might be true but I still feel that we should have done better. Rheumatologists are continuing to strive for better and better outcomes for our patients with rheumatoid arthritis.
The goal posts have moved, and during my career, I expect them to move much further.
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.With so many biologics for Rheumatoid, how do you choose?
By Dr Irwin Lim, Rheumatologist
I’m over the jetlag. I think. The brain fog lifted sometime this am.
The 2 days I spent in Leeds discussing rheumatoid arthritis with 20 rheumatologists from around the world seems like a blur.
One key discussion point needs review and I write down my thoughts today, to help you understand but also to force me to document this before I forget!
In Australia, we are lucky enough to have access to 8 biologic DMARDs once a patient with rheumatoid arthritis is deemed to have severe enough disease and has jumped through a range of hoops to meet set criteria. Now, it would be really nice to be able to work out which medication would be most useful for that individual patient sitting in front of me.
People, patients, respond differently to different therapies. Clinical trial results tell you about how a group responds. Not specifically about the patient sitting in front of me. Of course, we use the scientific evidence that we have to try to make an educated guess. But, it’s sometimes not so easy.
With this in mind, I asked the question.
How do you choose what biologic to use?
This diverse group of rheumatologists were from the UK, Spain, Finland, Germany, Russia, Kuwait, Israel, Brazil, Mexico, Columbia, Poland and Australia. There were clinicians and researchers, young and old, those who worked in the public hospital system and those in private practice.
The following is a synthesis of what I took away from the discussion and my own evolving practice.
Please do not take this as prescriptive. There is insufficient clinical trial evidence to be certain and as new head-to-head trials are reported, my approach and choices will likely change.
- The 1st choice tends to be a TNF inhibitor, and the 2 used most commonly are Enbrel (Etanercept) and Humira (Adalimumab). This is not surprising given the TNF inhibitors were the 1st class of biologic agents available for rheumatoid arthritis. Enbrel and Humira were the 1st 2 subcutaneous agents, are generally effective and reasonably well tolerated with good patient registry data over the decade to monitor for safety. Rheumatologists, and doctors in general, tend to be creatures of habit, so it makes sense that they stick with what they know until there is compelling evidence to make them change.
- Remicade (Infliximab), which is a TNF inhibitor that is given intravenously, is used more in places/centres where there is easy access to infusion rooms.
- If the patient does not respond at all to the TNF inhibitor (primary failure), most would change the class of biologic agent. By this, I mean that they would use a non-TNF inhibitor. The choices are Mabthera (Rituximab), Actemra (Tocilizumab), Orencia (Abatacept). Which of these will be used first up after TNF inhibitor failure is quite variable.
- If a patient has evidence of latent Tuberculosis (Tb) or is at very high risk of Tb exposure, we would typically treat with drugs to treat the Tb. These would be started prior to the commencement of biologic agent and then overlapped for some months. In the era prior to Tb prophylaxis becoming standard, there were less cases of Tb reported with Enbrel and so for some, that is the TNF inhibitor of choice when Tb is an issue. Some would prefer to use Mabthera as this medication does not seem to increase risk of Tb but most countries do not allow Mabthera to be used as 1st line treatment so access is difficult.
- If there is a history of cancer, it is likely to be safe to use any of the agents if the cancer has been treated and not recurred for at least 5 years. Most however, were keen to use Mabthera (if it was able to be accessed) particularly if the cancer was non-Hodgkin’s lymphoma as Mabthera is very effective for that condition.
- If the patient has multiple sclerosis or a family history of such, most would generally avoid TNF inhibitor therapy (but it was noted that the evidence is still uncertain if there is a link between these agents and multiple sclerosis).
- If there is evidence of skin or any other vasculitis, or an overlap syndrome (meaning that the patient seems to be having a combination of different autoimmune disease such as rheumatoid and lupus) or possibly in the setting of chronic leg ulcers, Mabthera would seem a good choice given it’s B-cell directed mode of action.
- When there is a high CRP, persistent anaemia, or elevated platelet counts, this may imply high levels of an inflammatory protein called IL-6. It that case, Actemra would probably be a good choice.
- If the patient has Hepatitis B virus infection, we need to avoid Mabthera & there is probably no great option among the other agents in terms of being more safe. Typically, anti-viral treatment will be needed.
- If the patient has Hepatitis C virus infection, the TNF inhibitors seem to be safe.
- If a patient suffers from chronic infections such as bronchiectasis, most would try to avoid TNF inhibitors. A common choice would be Orencia given the feeling that this medication causes less infection.
- When a patient has Interstitial Lung Disease, some would avoid TNF inhibitor therapy and try to access Mabthera instead.
- If the patient already has a prosthetic joint, for eg, a knee replacement, some argued that this would be a relative contraindication for TNF inhibitor use as the infection risk is higher. Especially if, the patient also suffered with chronic leg ulceration.
- Most agreed that Abatacept had a lower rate of infections. In some countries, this medication is not currently used much due to the current lack of availability of the subcutaneous formulation but this will change in the future.
- Mabthera would be a good choice in patients who are seropositive (have positive RF and anti-CCP) and who have hypergammaglobulinaemia (raised levels of a protein called IgG). This does not mean that these patients will not respond to the other agents. Just that these are the characteristics of patients who respond to Mabthera.
- In patients who need treatment while attempting to fall pregnant, the TNF inhibitors are likely to be safe even if the pharmaceutical companies would be unlikely to actively encourage use in this subgroup of patients. Enbrel or Cimzia had been used among the group.
- If very obese patients, subcutaneous biologic patients may not work as well due to poorer absorption.
It’s complicated, isn’t it?
I again highlight that these are certainly not guidelines. They represent a combination of evidence, some extrapolation of scientific principles, and the clinical experience of a range of rheumatologists.
I hope this gives you some insight as to the amount of thought that your rheumatologist puts into their decision making.
I’d love to hear the thoughts of my rheumatology colleagues reading 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.Follow Us!
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