Your Rheumatologist: partnership vs paternalism?

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Image courtesy of photostock/ FreeDigitalPhotos.net

Image courtesy of photostock/ FreeDigitalPhotos.net

By Dr Irwin Lim, Rheumatologist

As I read patient comments on social media, I get the sense that many yearn for their rheumatologist to be a partner in navigating their disease and helping them make their treatment decisions.

Rheumatology is difficult. Much of what we treat, and especially with autoimmune arthritis, is chronic, and can have profound effects on patients lives. Treatments can be complicated and scary. We are sometimes guided by scientific evidence, sometimes by experience, and often by our sensitivity, the art of medicine.

There is no doubt that for many of my patients, we work together in coming to decisions.

There are however, equally many patients, that to my mind, do not or cannot take a more active part in their management decisions. Some find it very hard to cope with the diagnosis and rather than go out and garner information, they avoid it.

At our clinic, we have created a lot of resources, both paper-based and web-based, to help education. I haven’t formally audited it but I have the sense that it’s appreciated by some and probably unused by many.

“Doc, just tell me what to do.” “You’re the expert.”

Often, I need to be directive and the patient needs to be directed.

It might be heresy, in social media circles, to talk about being paternalistic. I don’t mean to court complaint.

It’s just that different people want and/or need different approaches. Sometimes, doctors get it wrong but most are trying to do the right thing for the people they care for.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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When is the best time to have your joint replaced?

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Knee XRBy Dr Roberto Russo, Rheumatologist

The answer to the above question used to be relatively easy to answer. The standard response used to be simply: when all other treatments have failed and the risks of the operation appear less concerning than the prospect of continuing to live with the pain of the arthritis. The focus of non-surgical therapies and interventions has been to retard the progression of the disease and to assist patients with their pain in order to delay the need for surgery for as long as possible.

Whilst this approach is effective in most patients for many years, over time there emerged an increasing proportion of patients in whom these conservative strategies fail and the dilemma of when to have surgery arises.

In that circumstance many a doctor would often refer that decision to the patient, saying ‘let me know when you are ready and I will arrange the operation’.

This is probably the case because clinicians find it very difficult to appreciate on an individual basis the impact of pain and impairment on the quality of life of their patients, despite quantitative methods of measuring quality of life being used in the research arena. As a result, I suspect many a patient chooses to suffer with their pain rather than commit to making such a decision.

Sadly, it is not uncommon for a patient to delay their decision for so long that when they finally choose to have the operation they find that they have developed other health problems which prevents them from proceeding to surgery.

So should clinicians be advocating for joint replacement surgery when symptoms demand rather than leaving it to their patients?

A recent article published in the October issue of the British Journal of Medicine (reference below) adds some interesting results that I feel are worth considering when reflecting on how to address the above question. The researchers evaluated the rate of serious cardiovascular events over 3 years, including cardiac death and myocardial infarction, following joint replacement surgery (of either the hip or knee) in a population of patients with moderate-severe osteoarthritis compared to a similarly affected group who did not undergo surgery. They found that:

  • The group who had joint replacement surgery were significantly less likely to experience a serious cardiovascular event (hazard ratio 0.56, p<0.001)
  • Absolute risk reduction within 7 years was 12.4% and therefore the number needed to treat with arthroplasty to avoid a serious cardiovascular event was 8
  • The significant risk reduction was independent of traditional cardiovascular risk factors.

Therefore, the conclusion of the paper was that primary joint arthroplasty has a cardioprotective benefit in patients with moderate-severe osteoarthritis of the hip or knee. This is reported to be the first time such an effect has been demonstrated.

The reasons that are presented to explain the findings include:

  • Physical activity increases following surgery
  • Reduction in pain leads to a reduced need for NSAID use and less psychological distress, both of which are thought to increase cardiovascular risk

These results, if replicated by larger longer term studies, would suggest that elective joint replacement surgery should be a term of the past.

Instead the decision to proceed to surgery once conservative therapies have failed is a recommendation made on the balance of health benefits (including a reduction in cardiovascular disease risk) to the short and long term risks of the procedure.

Reference:

1. Ravi B, Croxford R, Austin PC, et al. The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis. BMJ 2013; 347: f6187 doi: 10.1136/bmj.f6187

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The window of opportunity to educate about rheumatoid

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By Dr Irwin Lim, Rheumatologist

I met her at the start of 2012. A young lady with a new husband. She presented with a very swollen knee. The diagnosis was rheumatoid arthritis and it was an easy one to make, given she had very raised autoimmune serology (RF and anti-CCP) and her mother also had the disease.

They were trying for a baby so treatment options were limited. And it was just the one joint involved, so treatment was localised to aspiration and cortisone injection.

I think I got to see her three times. Then she disappeared. She cancelled a follow-up appointment, said she’d reschedule, and didn’t.

In a busy rheumatology clinic, it’s hard to have a good follow-up system for patients who don’t want to return. And, I forgot about her.

She’s now back. And the rheumatoid is rampant.

Over 21 months since review and she now has over 20 joints involved, both big and small. Her fingers are all deviated at the MCP joints (knuckles), her wrist movements are restricted and her thumbs are shaped like a Z.

The window of opportunity to switch off her rheumatoid is well and truly over. We missed it.

I had a window period to educate her on how serious her disease could potentially become. I missed that.

I figure all rheumatologists would spent a lot of time up front trying to explain this beast called rheumatoid arthritis. I thought I was relatively effective at this but this sort of occurrence brings me back to earth.

Why didn’t she return?

Well, she was still trying to fall pregnant. And she thought that as long as she was trying, she couldn’t be treated. I suspect she has had difficulty coping with having a chronic disease and just plodded along, accepting her symptoms. Even now in the face of very active, deforming rheumatoid, she tells me she is coping and has little pain.

I feel disappointed and sad at what’s happened. Especially as it was likely to have been preventable.

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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Help us design the Rheumatology Centre you’d like to attend

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Our Parramatta clinic

Our Parramatta clinic

 

By Dr Irwin Lim, Rheumatologist

BJC receptionEffective space. This has been on my mind a lot recently.

Our most established clinic is based in Parramatta, a suburb in Western Sydney.

We’ve been in a 2-storey house since 2005. During this time, we’ve grown and added new staff and new services, squeezing ourselves into all corners, redividing rooms and making do with what space we have.

This has meant compromise. The workflow could and should be much better. We lack a room for staff to congregate. We would love more space to enhance the experience for our patients.

There’s 2 years left on the lease so we’re starting to plan.

A huge, somewhat scary move for us.

Small group exercise area

 

In this planning phase, we’ve decided not to worry about budget and cash flow. I know. Wishful thinking.

BJC IL room

As it stands, we want a site to accommodate:

  • 6 Consulting rooms, to be used by doctors, a nurse, a rheumatology educator, allied health professionals
  • 1 room for musculoskeletal ultrasound
  • 1 room to house a Bone Densitometer
  • A pathology collection area
  • 6 treatment rooms for physiotherapists
  • 2 treatment rooms for remedial massage therapists
  • Office space for the physiotherapists/exercise physiologists
  • A compact central gym area including space for small group exercise classes
  • An area next to the gym for biomechanical testing/assessment
  • Showers & Toilets
  • 2-3 offices, to be used by administrative workers, the practice manager & the managing director
  • A large staffroom which can also function as a small (20 seat) lecture theatre/staff meeting space
  • The staffroom needs to incorporate a functional kitchen which can be utilised for group healthy cooking demonstrations
  • A reception area with space for 5 front-line reception staff
  • A range of seating options for patients & their families
  • An area built for patient self-education utilising smart pads or computers (ala Apple Store)
  • An area to display & demonstrate useful products & devices which are used in managing arthritis
  • An area for kids with TV, DVD, books to entertain

I’m thinking lots of glass, natural light, and parking!

Can you think of anything else that you would like to see in a rheumatology centre?

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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Fish Oil: will you now use this for Rheumatoid Arthritis?

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Courtesy of photobucket.com

Courtesy of photobucket.com

 

By Dr Roberto Russo, Rheumatologist

Fish oil has literally become the flavour of the month!

So much so that there are now a host of variants available on the shelf, including Super Fish oil, liquid fish oil, and Krill oil, with each option promising an advantage over the other! The popularity of the product seems to be ever increasing, particularly in the management of cardiovascular disease and joint conditions. The latter is the primary focus of this article.

The beneficial constituents of Fish oil are the omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA). These have been shown to suppress inflammatory mediators including:

  • Proinflammatory lipid mediators
    • Prostaglandin E2
    • Leukotriene B4
  • Peptide mediators
    • TNF-alpha
    • IL-1 beta

These are effectively the same inflammatory mediators that are inhibited by the use of NSAIDs and the biological TNF blockers (albeit at a much lesser extent), thereby providing a biological plausibility to their use (especially in inflammatory joint conditions)!

However, the amount of EPA+DHA required to obtain symptomatic benefit in this context is relatively high at greater than 2.7g each day, which is more than is required for cardiovascular benefit.

The standard Fish oil capsule contains about 400mg of EPA+DHA and as such a patient would need to take at least 7 of those capsules a day, which would challenge even the most ardent of patients to comply with such a regime!! No wonder there are so many options available (as mentioned above).

But does Fish oil have a real benefit in patients with Rheumatoid arthritis, especially in the context of the modern management of the disease, which often involves the use of a combination of immunomodulating drugs to render the disease into remission?

That is the exact question that a group of our colleagues from South Australia set out to answer.

They chose to divide a cohort of patients with early Rheumatoid arthritis (defined as <12 months) into two groups, whereby one received 10mL of liquid Fish oil (providing 5.5g/day) and the other a low dose equivalent to 400mg/day, which is the dose often taken for cardiovascular disease.

Both groups were then treated for their disease according to the current standard approach, whereby disease modifying medications (DMARDs) were introduced in sequential order (including TNF blockers if required), with the aim being to achieve remission (a strategy termed treat to target).

What they found was the group receiving a high dose of Fish oil:

  • Required a shorter time to achieve a meaningful improvement in their disease control
  • Achieved a higher the rate of remission (according to the American College of Rheumatology criteria)
  • Had a lower failure rate to triple DMARD therapy, thereby requiring less use of TNF blockers
  • Required less use of NSAIDs

No differences though were found in overall disease activity, dose of Methotrexate or Prednisone used, or physical function.

The concern for an increased risk of bleeding was not found in their study, albeit I would remain cautious in prescribing Fish oil in those on blood thinning medications such as Warfarin or a combination of anti-platelet agents.

In conclusion, it would appear that there are indeed benefits to be gained with the use of high dose Fish oil as an adjunct to the current approach of treating Rheumatoid arthritis.

I would encourage you to read the article in full, which can be found in the Annals of Rheumatic Diseases (reference given below).

Whilst I am already in the habit of suggesting my patients take Fish oil, these results strengthen my conviction in this recommendation and remind me to ensure they are taking a sufficient amount.

I look forward to reading similar high quality research regarding the use of Fish oil in other joint diseases, especially in Osteoarthritis.

If you are a doctor, I would be most interested to know if you recommend fish oil, and if so what doses to you suggest?

If you are a patient, have you been recommended fish oil, and if so what doses do you take?

Reference: Proudman SM, James MJ, et al. Fish oil in recent onset Rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Annals of Rheumatic Disease, 2013; 0: 1-7. doi:10.1136/annrheumdis-2013-204145

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