It is one of the most common rheumatic diseases. Only in Poland it concerns about 380 thousand. people. As many as a quarter of them are not diagnosed, because you have to wait months for an appointment with a rheumatologist. This is a time of suffering, because the inflammation behind rheumatoid arthritis (RA) is manifested by excruciating joint pain. Some patients are not able to perform the simplest tasks, such as tying their hair or screwing in a light bulb. We talk to the drug about the challenges of living with RA and what treatment patients can count on. Bartosz Fiałek, head of the rheumatology department and deputy medical director in the Independent Public Complex of Healthcare Institutions in Płońsk.
- RA is an autoimmune disease in which the joints become inflamed. The main symptom is their pain and swelling
- Not all patients respond well to drug therapy. Biological treatment is an option, but although reimbursed, it is not easy to implement. The reason is the strict eligibility criteria for drug programs
- – In the United States (…), the criterion is the effectiveness of conventional treatment or the lack of it, and in our case we have additional “flavors”, which make the patient ill, fail to record the effectiveness of treatment, suffer from pain, not always qualify for treatment because the parameters of the scale that determine disease activity are, for example, insufficiently elevated, the drug indicates. Bartosz Fiałek
- Every fourth patient with rheumatoid arthritis is not diagnosed. The cause is usually a long wait to see a rheumatologist. There are only 1,7 thousand specialists in this field of medicine in Poland. For comparison, there are 4,4 thousand orthopedists, and over 5 thousand cardiologists.
- More information can be found on the Onet homepage
Paulina Wójtowicz, Medonet: How many patients in Poland suffer from rheumatoid arthritis?
Bow. Bartosz Fiałek: Global statistics say that RA is a problem of about 1 percent. population. So if we have about 38 million inhabitants in Poland, it turns out that almost 380 thousand people suffer from rheumatoid arthritis. people. Such statistics were also provided by the government some time ago. Unfortunately, not all sick people are diagnosed. It is estimated that up to 25 percent. patients do not know that they have RA.
What is this caused?
First of all, limited availability to specialists in the field of rheumatology, which is associated with a long waiting time for an appointment. This is due to the malfunctioning of the health care system in Poland, which is extremely underfunded and suffering from staff shortages. The consequence is often delayed diagnosis, i.e. diagnosis when the disease is already in an advanced stage.
What symptoms do RA patients most often report to you?
Joint pain and swelling – these are standard symptoms of rheumatoid arthritis. They usually affect the small joints of the hands, often the wrist, and also the feet. Sometimes they are so strong that patients have a problem with combing their hair, women cannot fasten a bra, men tighten screws or replace light bulbs. Of course, there are also less specific symptoms such as chronic fatigue, low-grade fever, and weight loss.
My guess is that not all joint pain qualifies for a diagnosis right away. When should the red light go on in your head, a signal that it’s time to consult a rheumatologist?
When joint pain occurs suddenly without a causal factor such as an injury, it is progressive and accompanied by swelling. Duration does not play a key role here, although the longer the symptoms last, the greater the risk that they may be a symptom of a more serious chronic disease.
I have patients who have been in pain for two weeks, but during the examination, it turns out that they have swollen more than 10 joints, and also elevated CRP and ESR, which in this case is related to the ongoing inflammation and allows for diagnosis. When patients come to me so quickly, I am happy because a quick diagnosis increases the chances of achieving remission, i.e. silencing the disease, and significantly reduces the risk of complications.
In addition to CRP and ESR, what tests are patients referred to with suspected rheumatoid arthritis?
The standard is to perform tests that fall within the classification criteria of RA, i.e. the aforementioned ESR and CRP, as well as RF (rheumatoid factor) and anti-CCP, i.e. determination of antibodies against cyclic citrullinated peptide. These four tests greatly increase the chances of a correct diagnosis of the disease.
If it turns out that the cause of the ailment is RA, I refer the patient to further tests that will allow for appropriate treatment to be adapted to the patient, and also to exclude contraindications. In the case of the first-line drug, i.e. methotrexate, we must rule out contraindications from the kidneys, liver and bone marrow; So I order peripheral blood counts, AST, ALT and creatinine.
Imaging tests are not necessary?
Not. X-ray examinations (X-rays) allow us to assess the stage of the disease, but they are not necessary for diagnosis. On the other hand, ultrasound examination (USG) of the joints is an auxiliary examination, because sometimes it really happens that the swelling is not visible. There are patients, usually at the beginning of the disease, in whom it is impossible to find out swelling on physical examination, arthritis is just “blooming”. Then imaging tests, such as ultrasound or magnetic resonance imaging, are very helpful. We can then assess whether the synovial membrane is overgrown, swollen, but also whether it is inflamed, or whether we have increased intrasynovial flow. These are indirect indicators that allow us to better assess the situation.
How is RA different from osteoarthritis?
They are two completely different diseases. It’s like trying to compare hypothyroidism with diabetes. This is what an endocrinologist deals with, but the background, course and treatment of diseases are completely different. Osteoarthritis is most often caused by overload changes, repetitive microtraumas, “wearing” of the joints. There are changes in the structure of the joint itself, which causes pain. In turn, RA is an inflammatory and immune disease.
Swelling of the joints is standard in the course of RA, and rarely in osteoarthritis. Morning stiffness in osteoarthritis is much shorter and usually lasts up to 30 minutes, while in the case of RA – even several hours.
The age at which patients most often contract or experience a relapse is also a difference. While osteoarthritis usually affects the elderly, the main flare-up of RA occurs in the fourth or fifth decade of life. Although there are of course cases when the disease manifests or worsens sooner or later.
And the similarities?
In both cases, joint pain is one of the main symptoms. However, while degeneration causes deformities and deformities in the joints, in RA the cause of pain is the ongoing inflammation of the synovial membrane lining the joint.
What causes this inflammation?
As in the case of most rheumatic diseases, also here we do not know the direct cause of the inflammatory process. The disease is said to develop in genetically predisposed individuals under certain conditions, usually in the presence of a specific factor, mostly environmental. This leads to an increase in the concentration of pro-inflammatory substances which, when combined with appropriate antibodies, can generate a specific set of symptoms.
Why is rheumatoid arthritis more often diagnosed in women than in men?
There are many theories. Some of them are related to genetics, others talk about the influence of sex hormones. It is probably a combination of genetics influencing the functioning of the endocrine system. Autoimmune diseases are generally more commonly diagnosed in women. A good example is systemic lupus erythematosus, which is diagnosed in women up to 16 times more often than in men. The occurrence of one autoimmune disease increases the risk of developing another disease of this origin. I have many patients who, in addition to RA, have Hashimoto’s disease, for example, hypothyroidism.
RA treatment evokes a lot of emotions among patients. There is traditional drug therapy, but not everyone responds well to it. There are also innovative methods, including the more and more popular and promising biological treatment, but not everyone deserves it. So what is the therapeutic path and what does it depend on?
We have treatments that influence the activity of the disease and treatments that only relieve symptoms. On the one hand, we have disease-modifying drugs, on the other hand, symptomatic drugs for pain that has not yet subsided, because, for example, we have just started a modifying drug, and most of them take time to work – with methotrexate, it is said, that from six to 12 weeks. So we use standard anti-inflammatory and analgesic drugs, sometimes we combine different substances, such as paracetamol with codeine or tramadol, and if that does not help, we give opioids.
Some medications prescribed by doctors are not very popular. Patients are concerned about taking them because of the common side effects. In this context, the most talked about is the already mentioned methotrexate. Are the concerns justified?
Methotrexate is the gold standard in the treatment of RA. The bad fame it is shrouded in, mainly in social media, is an element of disinformation that we know well, for example, in the area of the COVID-19 pandemic. Some person read or heard something bad about the drug on the Internet and passes this information on, although the message was devoid of reliability and scientific background. In my entire history of treating RA patients, I had one patient who refused methotrexate despite clinical indications. Most of the people who have doubts are convinced by the arguments about the legitimacy of the drug, its effectiveness and safety.
Of course, like any drug, methotrexate can cause side effects, but personally, I have had a few, maybe a dozen, and I have been treating RA for many years, in three-digit number of patients. It is a first-line drug, so it is most often prescribed in the treatment of rheumatoid arthritis, and statistically, if there are side effects, it applies to this drug.
Which side effects of methotrexate are the most common?
While taking methotrexate, gastrointestinal complaints may appear, i.e. nausea, vomiting, malaise. The erosions in the mouth and hair loss occur less frequently. There are also laboratory contraindications, i.e. clinically nothing happens, but when monitoring the effect of methotrexate on the body, it turns out, for example, that creatinine has increased significantly due to therapy and the drug should be discontinued.
What is then offered to the patient?
It all depends on what the increase is and what parameters it concerns. We can reduce the dose by half or stop the drug for a while to normalize the parameters, and then turn on and see how the body reacts to its reintroduction and whether the substance was actually the cause of the laboratory abnormalities, or for example a coincidence with another condition, such as infection or the addition of new drugs. Of course, we are also considering using a different drug. We also always analyze the general health of the patient.
Generally, in addition to methotrexate, in the treatment of RA, we can resort to leflunomide, sulfasalazine, which is also an effective drug, referred to as a second-line drug, and hydroxychloroquine. The latest recommendations of the ACR, i.e. the American Rheumatology Society, indicate that in the case of low disease activity, treatment can be started not with methotrexate, but with hydroxychloroquine. Therefore, we have quite a lot of treatment options for this disease, and apart from the aforementioned conventional substances, there are also innovative therapies.
I am going to ask which RA patients who respond poorly to first- and second-line drugs are most interested in it – biological treatment. This therapy, although reimbursed, is not available to everyone. Why?
Due to the strict criteria for including the patient in the drug program. The biggest problem is the fulfillment of the basic criterion, i.e. the lack of effectiveness of conventional drugs, their possible intolerance or the presence of contraindications to their use.
This is where time comes into play. We have to show the ineffectiveness of conventional treatment for three months, then change the substance and use it for another three months – also unsuccessfully. We can also combine the two drugs, although this regimen increases the risk of side effects. Only the ineffectiveness of the above-mentioned regimens or their intolerance, or contraindications to their use, are proven to entitle us to start the process of preparing the patient for innovative treatment.
A standard patient treats RA for about six months, and then waits to qualify for biological treatment. It may take another six months before this treatment is started. This is based on the assumption that he is not taking medications because of contraindications or intolerance, or that the medications used are not bringing the expected results, so the pain is bothering and the high inflammation persists.
Is inflammation taken into account in this type of criteria?
In some programs, yes – the patient must obtain the appropriate minimum points on the disease activity scale, which is based on one of the parameters of inflammation (ESR, CRP) and related clinical symptoms, such as pain and swelling. This is a paradox, because some patients due to an active disease, which, however, is not associated with significantly increased inflammatory markers, may not meet this minimum – then they do not qualify for the program.
In the United States, it is thought much better – the criterion is the effectiveness of conventional treatment or the lack of it, and in our case, we have additional “flavors”, which mean that although the patient is sick, the treatment fails, suffers from pain, it is not always eligible for biological treatment as the scale parameters determining disease activity are, for example, insufficiently elevated.
How many patients are affected by this problem?
He reacts badly to conventional treatment, does not respond or cannot use it over a dozen or several dozen percent. patients with RA. It is said that in the case of RA, about 20-30 percent. patients should be treated in an innovative, biological way. In Poland, however, taking into account the difficult to meet criteria for qualifying for drug programs, this form of therapy is actually used by a few percent. sick.
What is the cost of biological treatment in Poland?
Very different because different molecules cost differently, and by the way, they are administered at different time intervals – sometimes every two weeks, sometimes every four, some every six months. Therefore, it cannot be averaged, although it can be said that the cost of biological treatment of RA patients until recently was several thousand. PLN per month. Currently, the costs of therapy are slightly lower, because on the one hand, there are more innovative preparations on the market and so-called biosimilars, i.e. biosimilars, which are slightly cheaper, have appeared. Currently, the cost of innovative treatment of a patient with RA is several thousand. PLN during the quarter.
For this you need to be aware that RA is a chronic disease. It cannot be cured, so healing is ongoing – and costs money all the time. In the event of a long-term remission, it is possible to modify the treatment, or even temporarily discontinue it, although such remissions are not common. In general, patients with RA are not easy in Poland.
What could improve their situation?
If we are talking about biological treatment, it is first and foremost enabling more patients to use it. Of course, not everyone diagnosed with RA is offered biological treatment right away. After all, the point is not that with every disease, even of a mild course, for which remission can be achieved with the use of conventional treatment, we should immediately leave with an innovative cannon, since this disease can be pacified with a smaller cannon. However, a few percent. treated innovatively in Poland, assuming several dozen in developed countries of the world, it is asking for someone to look more favorably at this therapy in our country.
However, the problem goes much deeper. Everything starts with a too late diagnosis, the consequence of which is a too late initiation of treatment – first conventional, then innovative. This, in turn, is due to the underestimation of rheumatology as a field of medicine and the shortage of doctors. About 1,7 thousand rheumatologists in a country of 38 million is not enough to be able to effectively and timely help over 300 thousand. people with RA. And yet these are only some of our patients, many of whom also struggle with other rheumatic diseases, i.e. inflammatory diseases caused by the immune system.
So there is a lot to do. It is comforting that rheumatology is one of the fastest growing areas of medicine. May we in Poland keep pace with European trends, investing in new medical technologies, using the already developed ones, thanks to which it will be possible to help as many patients as possible.
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