American College of Physicians: Internal Medicine — Doctors for Adults ®

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Treat RA early, aggressively for best disease outcomes

By Ryan DuBosar

About 70% of the damage from rheumatoid arthritis (RA) that shows up on X-rays occurs within the first three years of disease onset. That leaves a critical window of opportunity for internists to initiate aggressive treatment, according to yesterday's scientific session on, “What the internist should know about co-managing patients receiving the latest immunosuppressive therapies.”

Recent research has shown that RA treatments given within 15 days of the initial presentation instead of four months later showed remarkable improvement in outcomes, said presenter John J. Cush, MD, a rheumatologist at the University of Texas Southwest Medical School.

“I'm asking you to assume a greater degree of responsibility,” Dr. Cush told internists in the audience. “The vast majority of people in primary care don't want to do this.”

However, the aggressive treatment following the initial visit of a patient with RA can save money from the $15.7 billion spent on hospitalization annually,” said Dr. Cush. “When they go into the hospital costs will skyrocket,” he said. “If we do better with what we do, we can drive down the costs overall.”

Internists should diagnose and treat patients aggressively, and then refer patients for more complex regimens using the latest disease-modifying antirheumatic drugs (DMARD) and biologics, Dr. Cush said. Internists are better at managing risk factors such as weight reduction, immunizations and osteoporosis, he said, while rheumatologists are more adept at using DMARDs and biologics for the most aggressive cases.

“You get them first, I get them later,” Dr. Cush told internists. “It's easier for me to make the diagnosis because they have full manifest disease at that point. They may not when they see you.”

Dr. Cush cited the following “12 commandments” of RA therapy (modified from Wolfe et al J Rheum 2002):

  • Make an early diagnosis
  • Assess risk factors for disease severity
  • Make a goal of remission (elimination of synovitis and disease activity)
  • Avoid undertreatment
  • Analgesics, NSAIDs and corticosteroids are palliative only
  • Early DMARD therapy is necessary and effective in all
  • Use the most effective DMARD (at optimal doses) first
  • All patients should be on methotrexate, DMARDs or biologic agents
  • Risk factors/comorbidities influence prescribed DMARD(s)
  • Use aggressive therapy when aggressive disease is evident
  • Measure disease activity and burden of disease
  • Treat to a goal (i.e., Health Assessment Questionnaire=0, Disease Activity Score<1.6, number of swollen joints=0)

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