What about a Clinical Protocol for Rheumatoid Arthritis Disease?

This was written in October 2011 as the fourth in the Frying Pan Post series. As most of you know, I’ve been crazy-busy since then, leaving many things on hold. These posts examine crucial ideas that have surfaced over the last couple of years on the blog. The Frying Pan Posts challenge the status quo in areas that seem critical to the lives of people living with RA. I’m going to publish this one as written, but there is an important update I’ll mention first.

UPDATE: New this week: the ACR has just published two items which could bring some progress if they are followed.

1. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. The full document downloaded as 24 pages. We’ll discuss it further in the future, I’m sure. It updates previous guidelines in the following areas: “1) indications for DMARDs and biologic agents, 2) switching between DMARD and biologic therapies, 3) use of biologic agents in high-risk patients (those with hepatitis, congestive heart failure [CHF], and malignancy), 4) screening for TB in patients starting or currently receiving biologic agents, and 5) vaccination in patients starting or currently receiving DMARDs or biologic agents.”
2. Rheumatoid Arthritis Disease Activity Measures: American College of Rheumatology Recommendations for Use in Clinical Practice. From the introduction: “Despite the push from various stakeholders in the health care system to standardized disease activity assessment in RA and growing evidence that treating to target is effective, most US rheumatologists do not routinely use standardized measures in clinical practice.” Six RA disease activity measures are now “recommended,” including some patient outcome measures we’ve discussed here.

Need for clear objectives for Rheumatoid patient care

What are the goals of rheumatology care for Rheumatoid patients? What are the implications for a philosophy of treatment or a standard of care for Rheumatoid disease? Vast differences in clinical care for RA exist, as we observe every day in our community.

Some areas where a clinical protocol would make a difference for Rheumatoid patients:

1. When to begin or modify disease treatment.
2. When and how to monitor disease activity.
3. When various additional specialists should be referred.
4. Interventions or procedures to offer patients.
5. Baseline testing of common issues associated with Rheumatoid disease.

Evidence of the fundamental need for a consistent RA protocol

1. A large international task force on treating RA to target recommended defining treatment targets for Rheumatoid disease. “Aiming at therapeutic targets has reduced the risk of organ failure in many diseases such as diabetes or hypertension. Such targets have not been defined for rheumatoid arthritis (RA).” They make suggestions which may allow for “optimal outcomes.”
2. On their website, the American College of Rheumatology (ACR) has published Practice Guidelines for Rheumatoid Arthritis: “The ACR has developed practice guidelines to reduce inappropriate care, minimize geographic variations in practice patterns, and enable effective use of health care resources.” In 2002, they published a pdf of clinical practice guidelines for RA which was updated in 2005.
3. Patients frequently wonder out loud whether being treated with DMARDs for RA is sufficient if they continue to experience the same symptoms and/or additional symptoms. Often they’re mistakenly told that it is.

What Rheumatoid patients need and why

Let’s make this very simple. People living with RA want to live as long and healthy as possible, doing as much as possible. Of course, they want to be able to walk a dog or brush their hair or cut their food.

They want doctors to use testing, treatments, or procedures that could promote that. If anyone else had bursitis or a swollen knee or carpel tunnel syndrome or problems with eyes, lungs, or heart, it should be treated. People with RA should be treated too, even though the RA may be the source of the problems.

The Frying Pan Posts:

• Rheumatoid Arthritis Swelling, Take Two
• 2 Reasons Monitoring Rheumatoid Arthritis Matters (More on treat to target)
• Rheumatoid Arthritis Exercise, Round 5

Click here to read more posts about comprehensive care. MUCH more to come.