Early use of DMARDs can prevent disability from rheumatic diseases - Dr. Mahboobur Rehman


 Rheumatology Conference Proceedings-II

Early use of DMARDs can prevent disability
from rheumatic diseases - Dr. Mahboobur Rehman

RA patients now speak at conferences and they have proved
better advocates about their disease-Hans Rasker

LAHORE: Dr. Javed Malik along with Prof. Tafazzul Mahmud chaired the second session during the International Rheumatology conference held here on October 13th 2012. Dr. Mahboobur Rehman from USA was the first speaker who talked about evolution of therapies; target concept in management of rheumatoid arthritis. He pointed out that not many patients get full remission. He discussed at length the safety of various medications, sustained response, cost and convenience of administration of drugs. RA, he said, is an old disease which was known even in pre historic era or the Willow Bark era. In 1876, Salicylic Acid was used which was followed by Aspirin, Gold Salts in 1929 and it was in 1941 that rheumatoid arthritis was recognized as a distinct entity by American Rheumatism Association. Results of treatment were so disappointing that Sir William Osler is reported to have said that when an arthritis patient entered my clinic from the front door, I slipped out from the back door. In 1905, treatment of rheumatoid arthritis became possible.

Dr. Abid Farooqui and Dr. Ahmad Saeed speaking at the rheumatology
conference held at Lahore recently.

Continuing Dr. Mahboobur Rehman said that in 1947, RA patients used to be hospitalized for two to three weeks and then they were allowed to go home. He then talked about the steroid and non-steroid era which was followed by conventional DMARDs era which was considered as the first revolution in treatment of RA. In 1998, leflunomide was used which was followed by the second revolution when biologic DMARDs were introduced. Treatment also included physical therapy, occupational therapy, rest, education, NSAIDs and then DMARDs. Now there is a new thinking which calls for treating early and treating aggressively. Inflammation is followed by joint infection, replacement of joints but sometimes the disease ends up with disability and irreversible damage. He emphasized on early damage control in Rheumatoid Arthritis.
Talking about early treatment of RA, he referred to the clinical window of opportunity. By the time the disease is established, 70% of patients already have radiologically damaged joints. Hence, very early treatment is better. Prescribing habits of physicians, he said, have changed. They believe in early use of DMARADs. What we have so far accomplished, he said, is significant symptom and infection control, improved physical activity, inhibition of structural damage and checking the progression of structural damage. Now we do not see those patients with structural damage in United States any more. He then talked about swam neck deformities. In patients with early RA, remission is the ultimate goal. Efforts should be made to preserve patients function and improve their quality of life. He then talked about extra articlar manifestations and pulmonary fibrosis. These patients die early. Women with rheumatic diseases have a risk of developing heart attack. He concluded his presentation by stating that with better treatment we have made a difference in saving joint disability and reducing cardiovascular morbidity and mortality.
This was followed by another excellent presentation by Dr. Hans Rasker from Netherlands who talked about guilt and shame in rheumatoid arthritis, He discussed in detail the joint inflammation and destruction, pain and stiffness, progression of RA, complications of RA and vasculitis. He pointed out that about 10-15% of RA patients die while 10-15% goes into remission. Course of the disease differs with individuals. Life is reduced by five years in RA patients but those with complications; their life expectancy is reduced by ten to fifteen years. Two third of RA patients have difficulty in walking, some lose job while some become dependent on others for dressing and use of toilet. Disease varies from hour to hour and day to day. There is uncertainty about the future of RA patients. They are unable to plan for future; they have less autonomy and all this results in change in their self image. Being dependent on others is their main problem and they are unable to do certain things themselves, hence their self image is badly hurt.
These RA patients, he went on to say, feel permanent guilt. They have a feeling that had they gone to consult the rheumatologist early and directly, they would have been much better. Some think it is a punishment from the God Almighty. He also referred to complimentary healers, wrong treatment being provided by doctors, use of different foods and psychological trauma. In RA stress is increased but it is not the cause of RA. All patients feel guilty, they feel they are a burden on others and they were not doing enough to improve their disease. I have seen patients with RA in their 30s. Egyptian RA patients, he said, feel guiltier than the Dutch patients.
All patients in Holland, Dr. Hans Rasker said are insured hence they can get all the treatment free. Women RA patients are more dependent on husband and the family. They have a feeling of shame because they did not go to the rheumatologist early. Some of them suffer from fatigue and are wheelchair bound. Some of them wear more rings on hands so that people will look at their rings rather than their hands. They also have a feeling that they are dependent on the family and shame for all of them. Referring to a study he said that young female patients feel more shame and blame themselves. Swimming in warm waters offers them some relief. Now the patients are much more educated. It is not uncommon to see patients who say doctor you read about my disease in detail and I will talk to you on this topic next week. Now RA patients speak at conferences about their disease and these RA patients are better advocates about their diseases. Patients serve as teachers and as scientists. They question about their disease, they are members of Ethics Committees and they want to be a part of the solution.
Dr. Abid Farooqui was the next speaker who gave details of Pakistan Rituximab Study- their experience with this drug in Rheumatoid Arthritis. He pointed out that now many biologicals are available. This Rituximab is economically priced biological DMARD. Since we have lot TB in Pakistan, this avoids flare up of tuberculosis not responding to standard treatment. This study was conducted a five centers in Pakistan and the patients paid for their own treatment. This drug is also used for many autoimmune diseases. The study evaluated how effective was its treatment, looked at the improvement in the patients activity. We also looked at the fact whether these patients improved further, how safe this drug was and how well these RA patients responded to this treatment. DAS28 scale was used for disease activity score.
Improvement with the use of this drug was seen in three different stages i.e. 20%, 50% and upto 70%. Cure in RA is still not possible. This was a Phase-IV study in which seventy five patients were enrolled, one dropped out hence seventy four patients were available for evaluation. All patients had about six month’s duration of disease. Patients who had moderate activity, bed bound or wheel chair patients, young children were all excluded. Similarly pregnant women, those breast feeding, those suffering from HBV or HCV were also excluded. Fifteen patients were male and fifty nine were female. Speaking about clinical features among these patients he mentioned morning stiffness, large joint inflammation, fatigue, occasional fever. Pain score improved after six months and after twelve months this improvement trend continued and the patients felt much better. After six months therapy, all patients showed improvement but they felt much better at twelve months. Overall non-responders were twelve patients. Twenty percent improvement was seen in 62 patients, fifty parent improvements was seen in 46 patients and up to seventy percent improvement was seen in 14 patients. Ten patients also reported complete remission of the disease. On induction, 14% of these patients had moderately severe disease, 86% had severe disease and many patients had treatment for long. On the whole, fifty patients reported good improvement while twelve had moderate improvement. None of the patents had any adverse drug reaction. His conclusions were that twelve months treatment with Rituximab is much better and this drug is very well tolerated. However, their sample size is small and further studies are needed with a larger sample size. Our patients, Dr. Farooqi opined had a big sigh of relief. Responding to a question he said that these patients had only two course of therapy and duration of disease may affect the results. These were the patients who had failed to improve on different DMARDs and all other treatment options had been exhausted. Most of the patients in this study were suffering from a very severe disease, he added.

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