An Easy Case of Rheumatoid

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By Dr Irwin Lim, Rheumatologist

My rheumatology colleague, Andrew Jordan just presented a rheumatoid arthritis case at our GP meeting.

A 60-something year-old lady presenting with swelling and pain involving the small joints of her hands. Early morning stiffness and some carpal tunnel symptoms. A pretty classic story.

The diagnosis was made even easier by the presence of an elevated rheumatoid factor in her blood tests, and raised inflammatory markers.

The GP was astute and referred her early. She presented to a rheumatologist within 2 months of the onset of her symptoms.

Methotrexate was commenced with a small dose of Prednisone to help calm her symptoms. Within a few weeks, Prednisone had been weaned and ceased. She continued only on Methotrexate and was doing well.

One and a half years since her presentation, she remains in remission, both from her point of view and from the point of view of DAS-28 remission. She is symptom-free with absence of synovitis, the swelling rheumatologists look for when they examine joints.

All this on Methotrexate alone. 2 small tablets (10mg each) once a week only.

Easy.

This is a near-perfect example of the window-of-opportunity.

Rob Russo then made a telling comment. A decade or two ago, it would be strange to talk about an “easy” case of rheumatoid.

And of course, many cases don’t pan out like this. Some patients have terribly aggressive disease. Sometimes, there are all sorts of logistical issues preventing early rheumatology review and early treatment.

There’s a lot of debate currently about the very expensive treatments we use for rheumatoid (read about triple therapy vs biologics).

There are massive cost savings to be had if we can treat patients early.

Within this window-of-opportunity, Methotrexate, a very cheap medication, works well for those who tolerate it.

Within this window-of-opportunity, this difficult disease becomes somewhat easier.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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Dinner Meeting vs Webinar for a GP talk

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By Dr Irwin Lim, Rheumatologist

2 more GP talks will end my speaking engagements for the year.

Next week, with my fellow rheumatologists, Herman Lau, Andrew Jordan & Roberto Russo, we’ll be presenting cases to highlight how ideas have changed surrounding a variety of the inflammatory conditions we treat.

This will be held in a private room at a local restaurant in the Hills District of Sydney. Dinner meetings rely on doctors being energetic enough after a long day at work to attend a talk. The dinner is usually so-so. The GPs listen and hopefully engage for a couple of hours. With Sydney traffic, it’s usually a fight to get to the venue. If the weather is bad, turn-out suffers.

We expect up to 15 GPs to turn up. Sydney GPs are apparently spoiled for choice with a variety of evening talks from different specialities through the week so turn out tends to be variable.

The following week, I’m presenting a webinar, my second (read about my 1st experience here).

It’s much more convenient for me. I’ll be home. No added travel. After the webinar, I can immediately get on with my usual routines.

I assume it’s more convenient for the GPs as well. I hope the webinar attracts different GPs, with different commitments, and at different stages of their lives.

ehealthspace invite

This time, we are aiming for a wider audience. The web solution being used can apparently cope with 50 people watching the webinar. Hopefully, there’s actually that much interest!

Still, it is a commitment to attend, either in person or on the computer. GPs are time-poor and many different craft groups are fighting for their attention. I’m not sure how they choose and it’s likely the GPs in most need of an update are least likely to attend.

So, trialling new ways to reach a broader audience and to make it easier to listen seems sensible.

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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Is it easy to forget to see your rheumatologist?

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A 6yo's interpretationBy Dr Irwin Lim, Rheumatologist

Saw a patient last week after an absence of 13 months.

Life apparently got busy and he “forgot”. At least, that was the reason given.

He’s on a disease modifying agent (a DMARD), which usually requires regular monitoring blood tests. He “forgot” these.

He didn’t attend his GP either. So no regular monitoring of any sort.

He’s now back because I wrote a recall letter reminding him of missed appointments and the need to be reviewed. His disease is actually relatively well controlled and thankfully, blood tests showed no organ damage.

This sort of scenario does happen from time to time. If the problem was me, I’d expect the patient to just ignore my reminder as they may be seeing some other rheumatologist or they may have decided not to be treated.

Can you help me understand this behaviour?

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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Biologic DMARDs have to get cheaper: here’s how

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injection devicesBy Dr Irwin Lim, Rheumatologist

I felt the need to write this follow up post.

The debate about Triple Therapy vs Methotrexate (read my last post to understand it) in rheumatoid arthritis exists due to the disparity of costs.

If both are similarly effective (it’s debatable which types of patients this statement applies to), we really should be using the cheaper alternative much more.

If both were similarly priced, I don’t think we’d be having this debate. I’m guessing most rheumatologists would choose the biologic/Methotrexate combo.

Wouldn’t it be good then if the price differential reduces?

This will occur. I don’t know how quickly or how much, but these are some ways:

Competition

The rise of Biosimilars: patents for biologic DMARDs are expiring.

While these are difficult medications to copy due to their molecular size and the complexity of manufacture, there are medications being reverse engineered to look like and act like the original. Already, there are biosimilars for Infliximab, Etanercept and Rituximab.

As these enter the market, I’ve heard estimates of 30%+ reduction in price.

Use biologic DMARDs earlier in strategies that allow cessation of the biologic

We may one day be allowed to use the biologic/Methotrexate combination upfront with a plan once the rheumatoid arthritis is well controlled to then stop using the biologic and hopefully keep disease control using the cheaper medication.

The OPTIMA trial is an example of this. Rheumatoid patients with early disease (<1 year & naive to Methotrexate, and this may be a key point) were given Adalimumab/Methotrexate. After 26 weeks, roughly half of those who had good disease control had the Adalimumab stopped. At the end of the study after 78 weeks, the outcomes were similar between the group that stopped Adalimumab and the group that stayed on it.

Reduction of the dose of biologic DMARDs 

Once patients achieve good control of their disease, some rheumatologists and some patients may reduce either the amount of biologic medication being given. This leads to flare in some but in others, disease control remains good. There is limited trial data for this approach but it’s a strategy likely to be explored.

Lower dose means less costs. Less frequent administration means less costs.

The PRESERVE trial is an example of this. The patient population was different to the OPTIMA trial, with later disease, and persistent, uncontrolled disease despite Methotrexate use. Rheumatoid patients who received a low disease activity score on the Etanercept 50mg weekly/Methotrexate combination were then randomised to one of three treatment groups: 50 mg Etanercept/Methotrexate, 25 mg Etanercept/Methotrexate, or placebo/Methotrexate.

The 2 groups using Etanercept, both the conventional & the reduced dose, maintained disease control better that the Methotrexate only group. The outcomes for the 2 different doses of Etanercept were about the same.

Thanks for all the comments regarding this topic on twitter and this forum. Please do continue to share your thoughts.

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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Triple Therapy vs Biologic/MTX: the debate rages

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injection devicesBy Dr Irwin Lim, Rheumatologist

I’ve been following the American College of Rheumatology Meeting in San Diego on twitter.

There’s been a fair bit of chatter regarding the relative merits of using Triple Therapy (Methotrexate/Sulphasalazine/Hydroxychloroquine) for Rheumatoid Arthritis compared to biologic therapy/Methotrexate therapy after the failure of Methotrexate as monotherapy.

I’d previously written about the thought-provoking O’Dell paper that has reignited this debate. Read it here.

There’s no denying that biologic therapy is really very expensive. All developed countries have budgets in deficit and the money printing will have to stop sometime. Health costs are soaring and we as rheumatologists are definitely adding to the bill.

This debate counts.

And yet, I must admit I haven’t changed my practice yet.

I sit here trying to justify why this is the case to myself and the points I’ve come up with:

  • Pill Load: With triple therapy, 2 or more tablets Methotrexate weekly, at least 1-7 tablets of folic acid weekly, 4 tablets of sulphasalazine daily, 2 tablets of hydroxychloroquine daily, add in some Prednisone early in the treatment cycle, possibly calcium and vitamin D supplementation, possibly fish oil. A patient will need at least 45-50 tablets a week.
  • With the 1st point, compliance is likely to be poor. Sorry, but I find it hard to believe most of my patients will adhere to taking all these.
  • Confusion. Mine. With different medication started together, it’s harder to work out if and when a side effect occurs, which therapy to blame? To enable me to stop or modify it.
  • The baseline characteristics of the patients in the trial reported seem different from mine. The patients had late disease, at a mean of 5 years post-diagnosis. They seem older than my usual group with an age mean around 57 years.
  • The patients had been on Methotrexate as monotherapy for at least 12 weeks and were doing quite badly with a high mean DAS28 of 5.8, mean swollen joint score of 11 and mean tender joint score of 13. Our treat-to-target mantra would usually have meant some combination therapy would already have been started unless there were good reasons not to.

Now, I’m likely just justifying what I do.

I still try to treat aggressively and I still treat-to-target, seeing my Rheumatoid Arthritis patients regularly while aiming for remission or a state as close as possible to this. I use Methotrexate then add in Hydroxychloroquine and/or Salazopyrin EN early if our targets are not being met. I just don’t tend to start the whole lot as described.

And yet, I do understand the financial imperative to use cheaper drugs if possible. After all, it’s your tax dollars and it’s my tax dollars.

If I had to pay and if you had to pay (rather than our funding bodies subsidising the treatments greatly), would we do something different?

The answer I think is (maybe) yes. We would use this triple therapy regime earlier. We would justify it better. Rheumatologists would cajole more.

And maybe, I won’t need this introspective yet on-line discussion. My funding body, the government, may eventually take it out of my hands and mandate that we use triple therapy as described as part of the process to gain access to biologic medication.

These are my thoughts. What are yours?

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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