With the advent of early, aggressive treatment and more effective drugs, rheumatoid arthritis (RA) patients are facing joint surgery much less than they were 20 years ago.
When rheumatologist Erdal Diri started working at Trinity Health Center in Minot, N.D., more than a decade ago, he saw many RA patients referred to him by surgeons frustrated by the levels of joint inflammation they saw. Better inflammation-fighting drugs and a new approach to treating RA more aggressively have changed that, he says. From an average of 30 to 40 RA patients per year being sent for surgery at this rural hospital, Dr. Diri now sends only 4 or 5.
Research Backs a Decline in RA Joint Surgeries
A study conducted by rheumatologists at the Mayo Clinic in Rochester, Minn., and published in Journal of Rheumatology in March 2012, tracked surgeries among 813 RA patients from 1980 to 2007. The researchers, led by Eric L. Matteson, MD, found that the incidence of any joint surgery within 10 years of diagnosis went from 27.3% in the 1980 to 1994 period, to 19.5% in the 1995 to 2007 period.
Surgeons also notice the decline in RA patients coming to their offices to seek joint replacements, notes Jeffrey N. Katz, MD, associate physician at Brigham and Women’s Hospital, and professor of medicine at Harvard Medical School. In the past, about 20% of the joint replacements performed by his department were related to RA; now they only perform 10% of joint replacements on RA patients.
Today, the RA patients needing joint surgery are mostly older patients who developed rheumatoid arthritis prior to the new crop of drugs coming on the market or people who have not had access to these drugs, including uninsured people and immigrants coming from poor countries where the treatments are not available, says Dr. Katz.
Inflammation Control Is Key to Preventing Joint Damage
Doctors now have many different weapons to fight inflammation in RA. The disease-modifying antirheumatic drug methotrexate is still the standard first-line drug used to treat RA inflammation, says Dr. Diri. If he doesn’t see results from methotrexate after about two months, biologic drugs are added. This is a big change from the approach to RA in the past, when doctors might wait several months to see if drugs were fighting inflammation – a period when irreversible joint damage might occur, he says. “Now, patients who are diagnosed with rheumatoid arthritis start with methotrexate and we get the biologic on board if they don’t respond. We don’t hang around too much anymore.”
The biologic drugs work in about half of RA patients, so rheumatologists can switch the patient to another treatment if one isn’t working, says Dr. Bathon. And because the drugs are more effective and are being used earlier to fight RA inflammation, we no longer see the need for multiple joint surgeries in these patients, she adds. “People quite often had hand surgery, foot surgery, shoulder replacements, knee replacements.,” she says. However, the new array of drugs to fight inflammation, including oral, infused and injectable biologic drugs, work well enough to offer people with RA a greater chance at a normal life, she says.
Educating PCPs and Medical Students About RA
The challenges for rheumatologists now include educating primary-care physicians and medical students to recognize the signs of RA early so patients can be referred for aggressive treatment before joint deformity can take place, says Dr. Diri. “When I observe students doing a rotation with me, when I mention even something like an anti-CCP (anti-cyclic citrullinated peptide antibody) test, they say, ‘Oh, is that new?’ And this student, in a few months, will be a physician! If they’re not educated about the new things in rheumatology, then they think that they can manage RA with NSAIDs or 5 to 7.5 milligrams of methotrexate a week, delaying appropriate treatment of the patient.”
Biomarkers May Help Improve Outcomes
Rheumatologists are also focusing on more effective, precise tests to determine which drug treatment is best for each patient, says Dr. Bathon. “Research in biomarkers is key. Is there a genetic polymer? Is there a particular protein marker in the blood? That’s where the field is heading.”