Rheumatoid Arthritis Therapy

Rheumatoid Arthritis Therapy

Health Promotion and Disease Prevention

Mrs. TT had numerous risk factors for severe rheumatoid arthritis, such as the presence of rheumatoid nodules, the fact that she is female, has a family history of severe disabling rheumatoid arthritis and radiographic changes of erosions and periarticular osteopenia, consistent with rheumatoid arthritis. In contrast, she did not have many of the other risk factors for developing severe, disabling rheumatoid arthritis, such as a positive Rheumatoid Factor, involvement of other organ systems, extra articular features (EAFs), low education and unemployment. It was essential however, to prevent progression of her disease and the presence of any comorbidities (28).

The overriding aim of current rheumatoid arthritis interventions is to prevent or retard clinical progression and radiological erosive disease as mentioned previously. We therefore immediately introduced combination therapy with disease modifying agents. Furthermore, we provided the patient with early access to a multidisciplinary team, as numerous sociopsychological factors are known to affect the disease process, such as poor social relations, depression, anxiety, and decrease work capacity. In order to prevent these outcomes, we introduced the patient to the Arthritis Society, which provides a multidisciplinary organized team approach to education, support, and disease prevention and treatment. Many professionals, including rheumatologists, physiotherapy (PT), occupationl therapy (OT), and social work (SW), participate to provide information about diseases and therapies. Numerous preventative services and support groups are offered, as well as educational sessions on diets, coping methods and self-relaxation(1,2).

Concerning physiotherapy and occupationl therapy , patients are taught how to perform muscle-strengthening exercises and how to protect joints during routine daily life. Moreover, ergonomic training, hand therapy, orthoses, foot care, and advice on other community resources are provided (29). In addition, the need to address other common associations, such as depression, and comorbidities, such as cardiovascular diseases, osteoporosis, and infections is essential (30). A comprehensive approach to Mrs. TT rheumatoid arthritis was therefore essential to promote her health and well-being, and prevent further deterioration of her state and progression of her disease due to additional factors. Education and counseling on the presentation of different comorbidities associated with rheumatoid arthritis (eg, SOB for cardiovascular/respiratory involvement) was done. This was accomplished through regular clinic visits and bloodwork monitoring. Patients like Mrs. X, who have participated in multidisciplinary programs, have revealed significant improvements in disability associated with rheumatoid arthritis, psychosocial interactions, and clinical prognosis, even within a short period of time (30).

Moreover, because of the presence of a history of diabetes in her family, Mrs. TT was encouraged to continue to exercise and maintain a healthy diet. Such modifications have allowed her to continue with her favorite pastimes and at the same time keep fit and active, as rheumatoid arthritis may predispose individuals to living a sedentary lifestyle through physical limitations. PT and adequate pain management, through ibuprofen, were crucial in further preventing these limitations. Furthermore, with great support from her workplace and community, she was able to continue to work.

Numerous screening tests were carried out at her initial visit (mentioned above) to assess for any rheumatoid arthritis comorbidities or EAFs, as well as the presence of other rheumatic and/or connective tissue diseases. Tests were appropriately applied in this situation. Screening tests to assess Mrs. TT glucose tolerance and lipid profile were not done; however, were suggested to her referring family physician, as well as to the patient. She had stated that these had been negative on numerous occasions on previous yearly checkups.

Professional Behaviors

It is crucial to provide early access to a multidisciplinary team, not only for treatment, but for the emotional and psychological aspects of rheumatoid arthritis (31). As mentioned above, rheumatoid arthritis patients need many different health care services and supports, thereby having a complex care demand and making appeals to different care providers. These activities have to be geared to one another and become integrated (32). The composition of the health care team that was involved in the patient’s care included a rheumatologist, a general practitioner, an ophthalmologist, a PT, an OT, and a SW. A pain care specialist was also recommended. Regular communication and understanding between these members, in all aspects of patient care, will involve disclosing each members care plans including treatments and investigations. This will have a positive impact on patient care, as well as decrease the economic costs of rheumatoid arthritis through effective resource management (2).

The rheumatologist was the leader of the team, as the knowledge and experience in rheumatoid arthritis diagnosis, prognosis and treatment, is best appreciated by these specialists. Coordination and allocation of the majority of services is in the hands of the rheumatologist. In addition to having the skills for effective clinical decision-making, the rheumatologist must have exceptional organizational skills in order to benefit both the patient with a positive health impact, as well as the medical community through a cost effective approach. The rheumatologist must have compassion, and a good ability to listen and communicate with the patient and team. Moreover, the rheumatologist is also the one who decides on whether a hospital admission is necessary, which in our case was not needed (31,32).

Evidence-based practice guidelines and consultations from rheumatoid arthritis specialists within the clinic, provided for exceptional care and cost effective management, achieving the highest level of care possible. For example, screening tests, including expensive serology tests (autoantibodies), where included only when indicated, and when there would be an impact/change on patient management and treatment. Laboratory studies, imaging and subsequent clinic visits, were appropriately tailored to prevent redundancy and coordinate resources between team members31. Concerning treatments, the patient was initially treated with first line combination therapy for rheumatoid arthritis (DMARDs), hydroxychloroquine ($0.52/day) and methotrexate ($0.43/day). Movement to expensive biologics, such as Remicade (> $25,000/year) would only occur with failure of the initially proposed treatment plan (following Canadian guidelines) (23,24). Preventative measures were also implemented, to prevent future detrimental and expensive disease associations, such as lung and cardiac disease. Primary and secondary preventative measures were taken, such as routine physical examinations and yearly eye examinations. Overall, this patient was managed in a very cost-effective manner, with an evidence-based approach. No unnecessary tests were done. 

However, depending on the particular time in the natural history of the disease, other members of the team will have to take the place of the most important member and become the leader. For example, the general practitioner who initially saw the patient and referred her to our clinic accurately suspected an inflammatory arthropathy and began the patient on a NSAID for effective symptom relief. Furthermore, the practice of a rheumatologist relies on mutual respect, trust and confidence between doctor and team members, as well as patients. Compliance and efficacy can be significantly improved by involving the patient, as well all members of the team in aspects of decision-making with regards to treatment. This can instill confidence in therapy and in the rheumatologist as the leader of patient management (31).

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