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The No.1 advance in a great decade for Rheumatology

Dr Irwin Lim is a Sydney-based rheumatologist. He blogs at BJC health. Follow Dr Lim on Twitter

I was asked by Edwin Kruys to guest post for the Panaceum Blog months ago. I was looking forward to it but have been procrastinating due to time pressures and being uncertain at how to pitch the post given the different audience.

Then I started to contemplate a pseudo-panacea for rheumatic diseases.

Panacea = A Remedy for all illnesses & difficulties

As this does not exist in rheumatology, I shifted my focus to what I would nominate as the No.1 advance in my rheumatology practice in the last decade.

This is simpler.

Biologic disease-modifying agents, and in particular, the TNF-inhibitor medications. Some of you may be on these and the trade names in Australia include Enbrel, Humira, Remicade, Simponi, and Cimzia.

These agents have provided a massive improvement in our ability to control the inflammation associated with diseases such as Rheumatoid Arthritis, Ankylosing Spondylitis, Juvenile Idiopathic Arthritis and Psoriatic Arthritis (they are also used for skin Psoriasis & for inflammatory bowel disease).

They are more effective than our older agents. On the whole, they are well tolerated. They virtually switch off the bony destruction that occurs with rheumatoid arthritis, and they profoundly improve the quality of life for the patients suffering from Ankylosing Spondylitis and Psoriatic Arthritis. They also reduce the very increased cardiovascular risks of these diseases.

This is starting to sound like an ad.

I need to give some balance to this. They are not right for some patients due to the side effect profile. And, these medications while tremendous advances, are very costly, and access by necessity is limited to save our tax dollars.

The reason I nominate the development and widespread use of the biologic medications as No.1 is because they have inspired a CHANGE IN ATTITUDE.

The goalposts have changed:

  • Because we have more effective agents which patients can only access after meeting certain criteria, we have actually learned to use our older therapies (e.g Methotrexate) much more wisely and effectively as we seek to test these criteria;
  • We tolerate less. Less damage, less loss of ability to perform daily activities. I would routinely ask a patient what they still can’t do that they would like to, and we strive to achieve those goals;
  • “With great power, comes great responsibility”. Rheumatologists now need to get off their backsides and work to increase awareness of these inflammatory diseases (as well as all the other rheumatic diseases which tend to be neglected). Effective treatment is still being deprived due to a lack of awareness among patients and their treating practitioners; 
  • In rheumatoid arthritis, time to rheumatologist is clearly a modifiable factor & greatly influences long term outcomes. We have learned that we need better ways to reduce the time for patients to present to their caring GPs, and then reduce the time for GPs to refer to the rheumatologist once the suspicion of rheumatoid arthritis is made, and then reduce the time waiting to see the rheumatologist given workforce shortages & Australia’s geographical issues.

It’s an exciting time for us rheumatologists. In truth, we feel more potent and there is more to come. The scientific endeavour has upscaled. New therapies are around the corner.

But, we mustn’t forget the simple things. Awareness. Patient education. Improved communication with our GP colleagues. Improved processes to help workflow.

I hope this post does help improve awareness a little.

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