A Window of Opportunity
By Roy Fleischmann, MD, Rheumatology Associates, North Dallas LIVING WELL Magazine
Rheumatoid arthritis (RA) is an aggressive disease that, if not treated adequately, results in progressive joint deformity that ultimately produces severe functional decline. Radiographic progression of erosive disease is the harbinger of disability. Most patients with RA develop radiographic damage within the first three years of disease, which then continues over the lifetime of the patient. Twenty-five percent of patients have evidence of erosions within one month of diagnosis and 80% develop erosions within the first year of disease. In addition to severe functional decline, inadequately treated RA also is associated with increased mortality. If adequate treatment is delayed for more than six months, there is a two-to-three fold risk of the development of significant disability five years later.
What tools should be used to assess whether a medication is effective or not?
The evaluation of a patient with RA should include measures of clinical symptoms, radiographic progression and patient function. Each of these variables have well validated tools which a treating physician can, and should, employ in order to determine whether a patient is being optimally treated. Clinical symptoms can be followed fairly accurately. This should be done on every patient at every visit. The goal is to treat to clinical “remission” or as low a disease activity as possible. Radiographic progression can be measured by a number of techniques. The goal of therapy is to halt radiographic progression. Functional status is also most commonly measured. The goal of therapy is to return as much function as possible.
How early should patients be treated?
Earlier treatment does make a difference. A report evaluated radiographic progression in two groups of patients, both treated with chloroquine or sulfasalazine. The first group was seen from 1993 to 1995 when it was the fashion to delay therapy because of concerns with respect to toxicity of these agents. This group was started on therapy a mean of 123 days after diagnosis. The second group, seen after 1996, when it was appreciated that earlier therapy was beneficial, was treated with the same therapy, a median of 15 days after diagnosis. The patients, who were treated earlier, even though the medications were the same, had significantly less radiographic progression at two years.
What Do We Really Need to Do In Practice?
The question should be, does the patient have any disease activity, no matter how mild or intense. If the patient has any disease activity, start the patient on single or combination of oral medication as soon as it is reasonably certain that the diagnosis is RA (sometimes even if not certain). Increase weekly, as tolerated and as necessary, to decrease disease activity to zero, using a validated measure of disease activity, which should be performed on every patient at every visit. If the patient has a plateau in improvement in disease activity, especially swollen joints, at two consecutive visits—add more therapy. Whatever medication is chosen, give it an appropriate time to work maximally, although at least some response should be seen by 12 weeks. If the patient has a poor prognosis or very active disease, consider therapy sooner rather than later
Treatment of rheumatoid arthritis should be as early as possible and as aggressive as necessary. An astute physician will use a disease measure to help guide therapy. Non-biologic therapy can be effective in controlling symptoms and have some effect on radiographic progression. Biologic therapies, especially in combination, are more effective in controlling clinical symptoms, slowing radiographic progression and maintaining patient function. Treatment can never be too early or never too late: The earlier the better.
Roy Fleischmann, MD, is a partner with Rheumatology Associates and co-medical director of the Metroplex Clinical Research Center. He is a clinical professor at UT Southwestern Medical Center and board certified in Internal Medicine with subspecialty certification in rheumatology.