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What would appropriate rheumatological care for RA patients look like? The ACR tells us that the majority of Rheumatoid patients do not receive treatment that follows their recommendations. What are some specific requirements for good rheumatology care for RA patients?
“Although the outcome of RA can be markedly improved by treatment with DMARDs and biologics, therapy is not ideal. Many RA patients still have significant symptoms and considerable disability. More needs to be done and achieving better results will depend on routinely measuring the impact of the disease in routine practice. All specialists should routinely record patient focused outcomes within routine care,” The consequences of rheumatoid arthritis: Quality of life measures in the individual patient.
What rheumatology care for RA patients should include
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1) The use of patient outcome measures: These specially developed questionnaires are the most dependable measure of disease activity and most reliable predictor of health outcomes. They also provide the most information with the least cost of time and resources.
2) An annual review of systemic RA effects: Tools must be developed in this area. In What kills patients with Rheumatoid Arthritis? we read: “Perhaps rheumatologists should consider revising the approach adopted in the routine assessment of RA patients by using an annual review form to include the systemic aspects of the disease in addition to its articular manifestations. This could be roughly analogous to the approach taken by diabetologists for decades, which has helped to reduce mortality…”
3) Baseline testing of cardiac function: Mayo Clinic rheumatologist and epidemiologist Sherine Gabriel stresses the “importance of performing a comprehensive cardiovascular risk assessment for all newly diagnosed Rheumatoid Arthritis patients,” Predicting Cardiovascular Disease Risk For Rheumatoid Arthritis Patients. She found the risk of serious cardiovascular event to be more than doubled with Rheumatoid Arthritis and that cardiovascular risk in RA patients is similar to those without RA who are 5 to 10 years older.
“Rheumatoid arthritis is a chronic, systemic, autoimmune disease that not only causes pain, stiffness, swelling, and limitation of function in joints, but also hurts internal organs as well. Approximately, 2.1 million Americans are afflicted with RA, most of them women… The notion that RA is a potentially crippling disorder is widely accepted. But, what is not generally known is that it is a potentially lethal disease leading to an increased risk of heart attack and stroke” Can Rheumatoid Arthritis Treatments Reduce The Chance Of Heart Attack?
4) Treating to target: Rheumatologists should be aware of and use modern approaches to RA treatment such a treating to a target of low disease activity or remission. A majority of patients surveyed say that treatment lacks goals and guidelines, Medical News Today.
5) Basic preventive eye care by an ophthalmologist knowledgeable about Rheumatoid disease: In addition to basic defensive eye care, RA patients should be treated by medical professionals who are knowledgeable about the effects of RA on the eyes and particular risks of medications used for RA.
6) Periodic and regular skilled joint examinations which include all joints patients say are affected: Our patients have frequently confirmed what several studies have reported about how seldom and insufficiently joint examinations are done.
7) Aggressive approach to treatment: This is critical since RA is active in the body for a long period before joint symptoms are evident enough to make diagnosis possible under current diagnostic criteria. Treatment is known to be most effective if it’s early and aggressive; since early treatment is often not achieved, an aggressive approach is even more important. A good explanation of intensive treatment approaches: Current Understanding of Rheumatoid Arthritis Therapy.
8 ) Shared decision making: This is a buzz word in health care that is an absolute necessity in rheumatology care. Rheumatoid disease is systemic, chronic, and progressive, requiring great effort and cooperation on the part of patients to execute treatments, monitor disease progression, and coordinate specialty care (similar to Diabetes care). A survey of 1892 RA patients found that “73 percent stated that their HCP (health care provider) did not discuss treating RA with an approach that achieved personal or social targets” Medical News Today.
9) Periodic imaging studies to review joint inflammation: Tools such as MSUS , MRI, or nuclear bone scan should be used to review joint inflammation unless it has been otherwise confirmed, such as by the presence of conspicuous swelling (found less than half of the time in 62% of patients with joint damage) or abnormal blood tests such as CRP or ESR (found negative in approximately 40% of cases).
10) Recommendations or referrals for non-drug therapeutic interventions: When specifically conformed to the needs of RA patients, physical therapy, occupational therapy, assistive devices, or joint supports can help people maintain mobility or moderate joint deformity. This should include other non-drug therapeutic modes of therapy such as massage, acupuncture, or access to warm water pools. While never a replacement for adequate medical care, non-drug interventions may sometimes allow people with RA to live with less pain, maintain greater independence and ability to continue working, or avoid social isolation and subsequent depression.
What RA patients should not endure in rheumatology care?
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1) RA patients should not be treated according to blood tests since there are no blood tests which can be universally applied. RA patients frequently state that their rheumatologist tells them by virtue of a blood test that their disease is “in remission” or “controlled.” There is no single blood test which diagnoses or confirms the presence of, extent of, or activity of Rheumatoid disease.
2) RA patients’ reported symptoms should not to be dismissed or blamed on emotions, defective pain processing or other syndromes or conditions. It is not prudent to suggest that well-recognized symptoms of RA are innocuous or due to harmless causes because doing so impedes necessary interventions.
More articles on recommendations for Rheumatoid Arthritis treatment
List of 15 recommendations from EULAR (European League Against Rheumatism): EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs.
List of 24 recommendations from the British Society for Rheumatology which has been cited by 107 other research articles as of this writing: British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis.
Clear explanation with simple tables describing current treatment practices for RA from Mayo Clinic: Rheumatoid Arthritis: Current Diagnosis and Treatment Practices. An excellent overview of currently recommended early treatment strategy, although an outdated estimate is used for the number of people with RA in the U.S.
Important related reading
- Significant Numbers of RA Patients Don’t Receive Recommended Care
- The HAQ’s, the RAPID’s & the Rest: 3 Reasons It’s a Moot Point
- Can We Treat the Whole Person or at Least the Whole Disease?
- What about a Clinical Protocol for Rheumatoid Arthritis Disease?
- Beginning Our 4th Year! 5 Stunning Things I Learned & My Forecast for the Future
- General Practitioners Need Basic Rheumatoid Arthritis Information
- We Refuse to Be Mislabeled: Updating Rheumatoid Arthritis (RA) to Rheumatoid Autoimmune Disease (RAD)
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