Patients with stable rheumatoid arthritis (RA) should not discontinue rheumatology medications without consulting a rheumatologist.
How should patients with rheumatoid arthritis (RA) be treated in accordance with global recommendations?
At the outset, it should be noted that at present Polish patients are well cared for when it comes to the availability of individual therapeutic options.
It is important to start therapy during the so-called therapeutic window, i.e. 12 weeks from the onset of the first symptoms. The introduction of treatment during this period gives a chance to avoid irreversible damage to the joints.
The first drug that should be used in the treatment of RA is methotrexate (administered subcutaneously or orally), which is started with a dose of 15 mg and gradually increased to 25 mg, of course, if it is tolerated by the patient.
Patients who do not respond to this treatment or have side effects should have a change of therapy. Another disease-modifying drug may then be used. However, when risk factors for poor disease prognosis are present – high ESR and CRP rates, a large number of swollen joints, rheumatoid factor and / or high titers of anti-CCP antibodies – biological treatment modifying the course of the disease can be applied immediately.
Today, access to specialist doctors is often difficult. What is the role of a rheumatologist and GP in the treatment of RA? Can the primary care physician continue treatment and issue prescriptions?
In my opinion, the care of a doctor of a different specialization than a rheumatologist may delay the need for a quick response which is necessary throughout the therapeutic process. The role of the rheumatologist is to modify the doses or change the preparation. It should also be noted that in the event of ineffective treatment, at some point we come to the stage where biological treatment should be started, which is reserved only for rheumatology centers.
On the other hand, there are cases where the patient’s disease is stabilized and then the cooperation of the rheumatologist with the family doctor is possible. It is also worth noting that the patient leaving the hospital receives an information card with a number of recommendations for internal medicine clinics or a family doctor. This cooperation is also possible, but patient care should not be performed only by a primary care physician.
What is the role of the patient in the whole therapeutic process?
There has been a trend in medicine that the patient should be a treatment partner. Equivalent enough that it is important that he has knowledge about the disease itself, its treatment and course. It should also be remembered that each patient is different, has comorbidities and that, for example, some medications will not be suitable for them. Therefore, even in the context of proper treatment selection, a dialogue between the patient and the doctor is essential.
RA significantly affects the patient’s daily life. What needs to be improved to make people with RA better live?
Individualization of treatment is extremely important – each patient should have the opportunity to use the therapy that will be most effective for him and thanks to which he will not have to give up his current life, but only modify it, which will allow him to remain social and professional. In this aspect, patients report shortcomings in terms of the possibility of using a biological drug. In their opinion, the timing of biological treatment implementation leaves much to be desired, in my opinion, the method of qualifying for this treatment corresponds to the realities and biological treatment is also possible in non-standard cases.
Another important issue that needs improvement is the interdisciplinary approach to treating patients with rheumatoid arthritis. In practice, this would mean that the patient should be looked after by both a rheumatologist, doctors of other specializations, a psychologist, and an employee dealing with social facilities and professional adjustment.
What are the symptoms of rheumatoid arthritis (RA) that should worry the patient?
In the typical course of the disease, the first to occur symmetrically (inflammation) occurs in the joints of the hands and wrists, and in the joints of the feet.
A characteristic feature of RA is the coexistence of pain, swelling and morning stiffness in the joints, lasting up to 3-4 hours after waking up. Some patients may experience general symptoms, such as a feeling of severe fatigue, muscle pain, low-grade fever, lack of appetite or a slight weight loss.
Rheumatoid arthritis in most cases develops within a few weeks, less often within a dozen or so days. It is important that a person who notices symptoms indicative of RA sees a specialist physician in order to make a proper diagnosis.
Why is it crucial to quickly diagnose the disease and introduce appropriate treatment tailored to the individual patient’s needs?
It is assumed that the time from symptom onset to treatment should be 3 months. This time is important because if there are structural changes in the joints, it will not be possible to undo them. Rapid diagnosis determines the effectiveness of treatment, and if it is started early enough, there is even a chance of permanent withdrawal of the disease. Successful treatment of RA means resolving the symptoms of the disease, good quality of life and maintaining fitness. It should be emphasized that untreated or improperly treated RA leads to motor disability and even premature death. It is also important that the treatment of rheumatoid arthritis is determined individually for each patient.
Patients with rheumatoid arthritis are one of the high-risk groups of severe COVID-19. What is a cause of it?
From the information we have so far, it does not appear that RA patients are more susceptible to SARS-CoV-2 infection. Data from December 1 show that 3590 patients with rheumatic diseases and COVID-19 were reported to the database of the European Rheumatic Society. Half of them end up in hospital. I have personally followed five patients who developed COVID-19 – four of them had mild symptoms and only one had a more turbulent course.
However, patients with RA are certainly prone to infections – both as a result of the disease itself and as a result of treatment. Therefore, these patients should strictly follow the principles of SARS-CoV-2 infection prophylaxis.
Why is it important for RA patients to continue their treatment?
Patients in a stable condition should absolutely not stop taking rheumatological drugs without consulting a rheumatologist. This is important because drugs protect them against the aggressive form of RA, on the one hand, and against the systemic complications of the underlying disease, on the other. However, if the patient is in a stable condition, has low disease activity, the doctor may decide to reduce the doses of drugs. However, those patients who develop SARS-CoV-2 infection should discontinue treatment and return to it within two weeks after recovery from COVID-19 – the entire procedure should be under the supervision of a physician.
I would also like to point out that with today’s treatment regimen, where all drugs are available through drug programs, including biological treatments, up to 80% of patients can go into remission.
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