Treat to Target: rheumatology reality or pie-in-the-sky?

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By Dr Irwin Lim

I’m lucky enough to be writing this from Prague. It’s around 4.30am and I am wide awake. Usual story with jetlag.

I’m attending an Immunology Summit here, with lots of the big guns in rheumatology presenting and sharing their perspective.

The overarching theme of the meeting is T2T.

Treat-to-target.

This is a concept well developed in Rheumatoid Arthritis. At the start of the disease, the rheumatologist involves the patient in a discussion about setting a target. Disease is then monitored regularly and the target measured. If the target has not been reached, the treatment is modified and usually intensified to reach the target.

Usually the target for the rheumatologist is a very low level of inflammation and some concept of remission. The target may be very different for the patient and more linked to symptoms and function. Some combination of both perspectives are aimed for.

By doing this, outcomes have been shown to be improved. Solid outcomes such as less joint damage, less loss of function and work, and improved quality of life.

At this meeting, the chairperson and steering committee were more provocative.

They extended this T2T concept to a range of other diseases we treat: Psoriatic Arthritis, Ankylosing Spondylitis & Spondyloarthritis, and Systemic Lupus Erythematosus (SLE).

Speakers framed their talks and discussions around this. Can outcomes be improved by treating to a target? What exactly is the target? How to we derive realistic ways to measure and document the target in diseases with protean ways to manifest themselves, meaning the symptoms and signs can differ between individuals and also differ between a specific individual at different timepoints.

Now, my disclosure is that I do believe, relatively strongly, in the T2T concept for Rheumatoid Arthritis. I want to believe in it for the other diseases but I do need to mull over it and we do need a more robust body of evidence.

There are plenty of skeptics, as to how T2T can be implemented in the “real world”. Here are some reasons why:

1) The problem with setting the target. This is not easy as already suggested above.

2) Measuring the target. The majority of rheumatologists do not perform composite disease measurements. The majority of rheumatologists do not use patient-reported outcome measures (apart from asking “How’re you doing?” or something similar). If you don’t measure and document, and rely on gestalt, it’s hard to implement T2T.

3) Seeing patients sufficiently regularly to implement the more frequent changes of treatment required to achieve the target. In active rheumatoid arthritis, patients should be seen 1-3 monthly. In locations where rheumatologist supply is an issue, or in very busy, resource-limited clinics, this is not viable and the time between clinic visits may be considerably longer. Also the time afforded to discussion to achieve a shared target is likely to be curtailed.

4) We still need long term data (except for rheumatoid arthritis I think) that more frequent treatment changes, and generally more intensive or potent treatment leads to more benefit than harm.

My bias is that the quicker and more completely one controls an underlying inflammatory disease, the better life will be for the patient, both short-term and in the very long-term.

I however appreciate there are caveats.

Share your thoughts?

AS frustrates, you & me!

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Courtesy of Photobucket/by mutantnoggins

Courtesy of Photobucket/by mutantnoggins

 

By Dr Irwin Lim, Rheumatologist

Ankylosing Spondylitis is such a frustrating disease. It’s under recognised and this then leads, to under diagnosis and often, inappropriate or inadequate treatment.

Why?

It’s not generally because people don’t seek treatment. It’s also not because health professionals don’t want to help.

  • It’s because it can be reasonably insidious in many. It’s a disease that can creep up on patients in some cases.
  • As it usually begins in early adult life, it’s so often blamed on something else. If you’re male, it must be sport or that lifting you did at work. It you’re female, it’s those pregnancies which caused it. It’s poor core stability…. It’s your poor posture….It’s how you have to sit for so long at work….
  • It may provide clues in areas remote from the spine. This gets treated by other unrelated health professionals and through lack of awareness or poor communication, the penny does not drop so 2 + 2 does not end up equalling 4. For eg, people with ankylosing spondylitis may get eye inflammation or they may have bowel inflammation or they may present with tennis elbow or heel pain….
  • Even if diagnosed, ankylosing spondylitis typically advances slowly over many years. Patients learn to cope and get on with life, and if they don’t attend regular follow-up with rheumatologists interested in the disease, this can lead to insidious decline in physical abilities and loss of function. For eg, Think of that slowly stiffening neck and the progressive difficulty with field of vision while driving…
  • Co-morbidities, such as osteoporosis usually develop silently. People don’t think about it so it’s not looked for or monitored.

The points I’ve listed above lead to late diagnosis or misdiagnosis. Patients often enter a merry-go-round seeing help from numerous chiropractors, physiotherapists, osteopaths, doctors etc, etc. They get frustrated and unfortunately, suffering is somewhat prolonged. Costs, including time and wasted opportunity, escalate.

It’s frustrating to all.

We need to keep working on improving awareness of this frustrating disease. Awareness among patients who suffer from chronic spinal pain. Awareness among the health professionals who may come into contact with various aspects of this disease.

BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.

Let’s discuss Vaccination with Biologic DMARDs

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By Dr Irwin Lim, Rheumatologist

Ampule and syringe on abstract coloured background.My rheumatologist mate, Ingrid Hutton, suggested I write this post.

I thought it best if I approached this by telling you what I do and then asking/hoping my fellow rheumatologists will add in what they do.

The reason this topic is important is that our patients who receive biologic DMARD (disease modifying anti-rheumatic drug) therapy have disturbed immune systems and will end up with a degree of increased immunosuppression on the medications.

Biologic DMARDs are used for rheumatoid arthritis, psoriatic arthritis and psoriasis, ankylosing spondylitis/spondyloarthritis and inflammatory bowel disease.

When I’m about to start patients on biologic DMARD, I suggest they have:

1) Fluvax (influenza virus vaccine). This is given yearly and should continue yearly once a patient in on the treatment. Of course, it does depend on the time of year and the proximity to flu season. While preferable to have the vaccination prior to the start of biologic DMARD therapy, the vaccine may not be available.

2) Pneumococcal vaccination. This helps prevent people from becoming infected with a particular type of bacteria called Streptococcus pneumoniae. This bacteria can cause pneumonia, sinus infections, middle ear infections, meningitis and septicaemia. It is given once and in some circumstances, it is repeated after 5 years.

What about other vaccinations while on biologic DMARDs?

Well, it’s really LIVE vaccines that must be avoided (these are attenuated, meaning the virus used is made much less virulent).

Live vaccines to avoid include:

  • MMR (Measles, mumps, rubella)
  • Rubella
  • Rotavirus
  • Varicella-Zoster
  • Yellow Fever
  • BCG
  • Oral Typhoid

Inactivated (non-live) vaccinations are fine to have. Patients who are immunosuppressed are not more likely to have an adverse reaction. However, the worry is that the immune system might not mount as good a response to the vaccination, meaning that the vaccination is not as effective.

Vaccinations that do not have to be avoided include:

  • Hepatitis A
  • Hepatitis B
  • HPV
  • Influenza
  • Rabies
  • Diptheria-Tetanus
  • Diptheria-Tetanus-Pertussis
  • Haemophilus Influenza B
  • Injectable Typhoid
  • Meningococcal
  • Oral Cholera
  • Pneumococcal

Preparing this post made me review what I do and what I should possibly be doing. My ruminations:

  • Timing can be debated. While many rheumatologists will consider vaccinations pre-commencement of biologic DMARDs, should we not be considering this with other drugs we use, such as corticosteroids especially at the higher doses eg 20mg daily. Should we consider this before starting traditional DMARDs like Methotrexate even if DMARDs like Methotrexate are not considered to be particularly immunosuppressive? Should vaccinations be optimised pre-treatment?
  • Shingles occurs more commonly in our patients on immunosuppression and in particular, when corticosteroids are used. It may also occur more commonly while on biologic DMARDs. Should I be attempting to vaccinate all patients? Or those who can’t recall having had chicken pox/shingles? Or those with low antibody levels only?
  • Should we aim for hepatitis B immunity in all our patients with chronic inflammatory arthritis? And if so, at what stage of management?
  • Should all my younger female patients have the HPV (human papilloma virus) vaccination if not already vaccinated to prevent cervical cancer, anal cancer and genital warts? Which males do we extend this to?
  • This all adds complexity and burden, as well as treatment delay to managing the patient you break the news of having a disease, for example rheumatoid arthritis, to. What is the benefit to doing all this vaccination at this earlier stage of disease, or indeed at the later stage of disease?
  • And while I sit and contemplate all this, is the issue actually public and doctor awareness of vaccination? Maybe, this needs to have already been addressed to some extent at the primary health and public health levels even prior to patients ever meeting a rheumatologist.

A rather complicated topic to write about. Now over to you.

What do you think about this?

What did your rheumatologist suggest for you?

And can some of the rheumatologists reading this please contribute to the conversation?

Thanks.

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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My grandma, arthritis, & the difficulty with diagnosis

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By Dr Irwin Lim, Rheumatologist

My grandmother lives overseas.

A couple of months ago, she developed pain and swelling in the joints. She gets the best care money can buy in the country she lives in so she did the medical rounds, and also explored, because her family are inclined that way, the complementary or “alternative” health options.

I received some emails and WhatsApp updates, and had to dabble in this case with advice from afar. This is always fraught with problems but as you will understand, it’s not something I can say no to.

She was given NSAIDs to try and help the suffering. I worry about this a little given she’s close to 90 years-old with a not-so-healthy heart, and old kidneys. I think she was given cortisone at some stage and this will of course help.

In the end, she did get to see a rheumatologist. Whew!

The rheumatologist diagnosed seronegative inflammatory arthritis and commenced her on Methotrexate at low dose, 10mg weekly.

There is some irony in this given I write about Methotrexate a lot to try and allay some misguided fears about this medication. Some of her family have read my blog and were reasonably comfortable with the medication.

As I am. Unless the diagnosis is not correct. Because, the drug is less likely to work in other conditions which can mimic autoimmune-based seronegative inflammatory arthritis.

Hand Swelling

Last week, the hand swelled diffusely and from the pictures sent to me, her elbow also appeared swollen. She would have been in a lot of pain.

The diagnosis needed to be reconsidered. In an elderly female, with the diffuse swelling at her hand/wrist, I usually worry about crystal arthritis, gout or pseudogout.

She was admitted to hospital for investigations and the diagnosis was changed to Pseudogout based on some changes seen on an Xray (I assume this was chondrocalcinosis), and an aspirate of joint fluid which did not show any infection (infection is unlikely given the multiple joints involved).

Methotrexate has been stopped and her medications rejigged.

Being in the game, I can definitely vouch that diagnosing the cause of inflammatory arthritis can often be difficult. Blood tests can often be unhelpful. Preliminary investigations may not provide any definitive features.

Many times, experience and judgement allow a best guess. And, all of us rheumatologists will get in incorrect some times. Being open to a rethink is important. Having a good enough rapport with the patient so that they trust/respect/like you enough to return when things are not going well is important.

We’re hoping the diagnosis is clearer this time…..but it may not be.

Sometimes, the passage of time and repeat review is the only way to clarify things.

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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Reflecting on my 1st decade as a Rheumatologist

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Image courtesy of Gualberto107 / FreeDigitalPhotos.net

ALUMINIUM: Image courtesy of Gualberto107 / FreeDigitalPhotos.net

By Dr Irwin Lim, Rheumatologist

Feb 2004. That’s when I left hospital confinement to set up private practice as a rheumatologist, fearful and excited. I think I saw 2 or 3 patients that entire 1st week. In Australia, patients present via referrals from their general practitioners and I was very unknown and unloved at that stage.

10 years on and it gives me an excuse to reflect. These are a few personal observations, noting that I practise in a well resourced, metropolitan environment in a comparatively rich country.

Hospital training does not prepare you for private rheumatology practice

The nature of hospital rheumatology with sicker patients on the wards; under-resourced, busy outpatient clinics with excessive waiting lists; and the constant pressure to speed through the lists and to discharge patients, did not ready me for the type of rheumatology I would see in private practice. Patients are different, expectations are different, the pathology presented is different.

I do however think I was taught a way of thinking and an approach to sorting out complicated problems.

My entire medical training did not include any teaching about small business, which is a big failing. I think the vast majority of rheumatology is practiced out in the community in Australia. Running a viable, small business is vital for the physician’s peace of mind and efficiency, and ultimately, better for patient care.

Private practice rheumatology can be invigorating

I recall being told by senior colleagues how private practice can be isolating and over time, the drudgery of attending to patient complaints and problems day-in and day-out can be draining.

This can of course be managed, in some settings better than others. The traditional model of rheumatology practice in this country with one consultant, a waiting room and 1-2 administrative staff may follow that script. I’ve however been lucky to work in a vibrant group practice with enthusiastic rheumatology colleagues and other complementary allied health colleagues. We teach and we learn from each other.

We hold educational meetings, case discussions, practice reviews. We can support and provide cover for each other during the essential holiday breaks.

As our treatments become more potent, rheumatologists need to have a higher profile

In 2004, a few months into my 1st year, government-subsidised TNF inhibitor therapy became available for rheumatologists to prescribe. We now have access to 8 biologic agents. There has been quite an explosion of knowledge and scientific trial data in the last decade with more to come.

Rheumatologists have become more useful to their patients, and it is imperative that our traditionally low profile improves. If general practitioners and the general public don’t even know what a rheumatologist is, and what we do, how will patients with the conditions we treat well, ever come in contact with us?

Subspecialisation is personally satisfying

The longer I’ve been in rheumatology practice, the more general physician skills I’ve lost. For example, I have not prescribed an anti-hypertensive for blood pressure since I left hospital. This is the GP’s domain. Working in a city, there are also lots of other specialists, all looking after their own part of the body.

The mix of patients I see is also more limited. I don’t get to see acute vasculitis very often, or very sick lupus patients with threatened internal organs. They get referred to the hospital.

I’ve developed a subspecialty interest in Ankylosing Spondylitis and spondyloarthritis, so I see a lot of that. It’s allowed me to be involved in awareness initiatives and allowed me to engage with and learn from colleagues far more expert than I am.

I also see a lot of rheumatoid arthritis and psoriatic arthritis because these are very prevalent in the community and we make a point to expedite review of these patients when highlighted by their GPs. Patients with these chronic diseases require regular follow-up and over the years, fill up a larger and larger percentage of available appointments.

Increasing specialisation is not necessarily good for the community but it’s nice to be the go-to-person for something (good for ego and professional development).

The rise of the patient

During my training, I would never have guessed that I’d be writing this blog. Twitter didn’t even exist. In 2010, I started to dabble with social media, and through this, I’ve been exposed to a range of patients’ comments. Some of this has been eye-opening and it has made me more aware that doctors can do better. In engagement, in improving awareness and in education.

While social media has provided a tool to speed things up, it’s the shift in mindset that counts.

It’s been a busy 1st decade for me. I’m still excited about the years to come and hope to continue to harness that feeling to do all the various things brewing and sprouting in my mind.

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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