There is a huge care gap in the treatment of rheumatoid arthritis in Canada, says Dr. Diane Lacaille, a senior scientist with the Arthritis Research Centre of Canada and an associate professor in the University of British Columbia's Rheumatology division.
"When looking at population-based data, we see that about half the people are not getting what is considered essential treatment," Lacaille says. Rheumatoid arthritis (RA) affects a relatively small number of Canadians - approximately 300,000 people - and she believes this is one reason for the deficiencies in care.
"When the average family physician has only a handful of patients with RA, it is difficult to become confident in treatment of the disease," she says. "A lot of family physicians are not aware of the major shift in how RA is treated or they are not referring patients to rheumatologists early. Then some family physicians or their patients are not comfortable with the treatment because of concerns about side effects. There needs to be a mentality shift at the level of the family physician and among the public."
A radical shift has taken place in the treatment of rheumatoid arthritis in the last decade. The disease can't be cured, but doctors are able to control it, prevent damage to the joints and improve the quality of life and lifespan of RA patients.
To achieve this, though, early diagnosis is crucial, says Dr. John Esdaile, the Arthur Child Chair in rheumatology research at the University of Calgary, a faculty member at the University of British Columbia and scientific director of the Arthritis Research Centre of Canada. "This is a big shift in thinking and I am not sure it has been accepted yet. Everything we have done over the last 30 years has shown that the earlier you get control of rheumatoid arthritis, the better."
"If we treat early, treat aggressively and treat to target - that is set a target and keep changing the treatment until the target is reached - we are able to prevent the terrible deformities (that RA can cause) in a large proportion of the people," says Lacaille.
"Our target is remission and we can get remission rates (no inflammation and no swelling in joints) in about half of the people - if treatment is started early."
Treatment for people with RA is traditionally with disease-modifying antirheumatic drugs (DMARDs). Those who do not respond to the DMARDs can be treated with biologics. As these medications - usually administered by intravenous infusion or injection - are designed to inhibit parts of the immune system, they may cause side effects, from minor inflammation or rashes at the injection sites to serious infections or flare-ups of other chronic diseases, such as tuberculosis.
"Yes, there are some side effects," says Esdaile. "These biologics can increase the risk of infection, but they don't seem to do that if you treat early and patients don't have damage to joints and lungs. It certainly looks as though the increased risk, if any, is much smaller if the disease is caught early. And the new treatments are miraculous in about half the people. If I had bad RA, I would start myself on one of these newer medications immediately because biologics arrest the disease."
The urgency of early treatment is clear. RA is "not a benign disease," Lacaille says. In addition to "really limiting physical function, it is also associated with increased risk of mortality, particularly from cardiovascular disease. If RA is not treated, people have severe physical disability and die prematurely. We used to just try to make people comfortable, but they were still getting the damage, the heart disease and dying prematurely. We now have very effective treatments that can completely stop the progression of the disease."
Dr. David Hart, scientific director of the Arthritis Society and a professor at the University of Calgary, says more research is underway to develop the next generation of biologics, "which will help even more patients and be even more effective for subsets of patients."
He adds the identification of more risk factors for RA will help with early diagnosis. "As more information is becoming available at the genetic level, it may be possible to start identifying people who may be at risk before they actually have the disease, so that they may be monitored. Hopefully, we could intervene early on before the disease is chronically painful and crippling. We are certainly on the threshold of this."
- Source: The Canadian Arthritis Network