Early Arthritis Clinic

Need for an Early Arthritis Clinic

Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by synovial hyperplasia, abnormal cellular and humoral immune responses and joint destruction that often leads to significant disability and increased mortality [1]. A delay in early diagnosis and treatment of the inflammatory arthritides can result in joint destruction with consequent disability [2] and psychosocial dysfunction [3]. RA is also often associated with comorbidities including cardiovascular disease and osteoporosis [4]. RA therefore is associated with substantial economic costs to the patients, their families and society [6]. The establishment of an early inflammatory arthritis clinic (EAC) in the Greater Rochester Community can facilitate early diagnosis and treatment of RA with the goal of preventing joint damage and subsequent disability.

A majority of patients with new onset rheumatoid arthritis experience significant delays in early diagnosis and optimal care [7]. There often is a delay in referral of patients with inflammatory arthritis to the rheumatologists. Some of the reasons for the delay include the following: primary care physicians (PCPs) may have not received adequate training to recognize early inflammatory arthritis; PCPs may be unaware of the availability of new medications that can adequately treat these ailments and finally because PCPs may have experienced long delays in obtaining rheumatology appointments for their patients. The latter has been particularly true to the Greater Rochester area due to a severe shortage of practicing rheumatologists in the area for the past several years. PCPs who do suspect a diagnosis may also be uncomfortable or unable to prescribe disease modifying agents/ biologic agents used in the treatment of RA.

Evidence-Based/Best Practice Innovation

RA is associated with progressive joint destruction and deformity with the majority of patients developing erosions within the first couple of years [13]. Early therapy with use of disease-modifying anti-rheumatic drugs (DMARDs) may improve clinical outcomes in patients with recent onset of RA compared with delayed treatment [14]. Multiple clinical trials have demonstrated that even a brief delay in starting DMARD therapy can negatively impact radiographic outcome. A recent trial suggested that treatment with DMARDs within 15 days of presentation was associated with a better outcome after 2 years compared with delayed treatment (median 123 days after presentation) [9]. Indeed, the American College of Rheumatology (ACR) has recommended that initiation of DMARDs should not be delayed beyond 3 months of diagnosis [15].

There is increasing evidence that the very early phase of synovitis in patients destined to develop RA (within the first 12 weeks of symptoms) represent a pathologically distinct stage of disease [1]. These findings suggest that very early intervention may have a qualitatively different effect compared with later intervention. Early diagnosis and aggressive treatment has therefore become the cornerstone for management of rheumatoid arthritis [16-20].

References

  1. Raza K, Buckley CE, Salmon M and Buckley CD, Treating very early rheumatoid arthritis. Best Practice and Res Clin Rheumatol 2006; 20:849-863.
  2. Sokka T. Work disability in early rheumatoid arthritis. Clin Exp Rheumatol 2003: 21 (suppl 31): S71-74.
  3. Dickens C, Jackson J, Tomenson B et al. Association of depression and rheumatoid arthritis. Psychosomatics. 2003; 44: 209-215.
  4. Gabriel SE, Crowson CS, O’Fallon WM. Comorbidities in arthritis. J Rheumatol 1996; 26: 2475-2479.
  5. Wolfe F, Mitchell DM, Sibley JT et al. The mortality of rheumatoid arthritis. Arthritis Rheum 1994: 37: 481-494.
  6. Allaire SH et al. Pharmacoeconomics 1994: 6: 513-522.
  7. Cush JJ. Early Arthritis Clinics: If you build it will they come? J Rheumatol 2003; 32: 1-4.
  8. Quinn MA and Emery P. Are early arthritis clinics necessary? Best Practice Res Clin Rheumatol 2005; 19: 1-17.
  9. Anderson JJ, Wells G, Verhoeven AC et al. Factors predicting response to treatment in rheumatoid arthritis. Arthritis Rheum 2000; 43: 22-29.
  10. March L, Lapsley H. What are the cost to the society and the potential benefits from the effective management of early rheumatoid arthritis? Best Pract Res Clin Rheumatol 2001; 15: 171-185.
  11. Cooper NJ. Economic burden of rheumatoid arthritis: a systemic review. Rheumatology 2000; 39: 28-33.
  12. Yelin E and Callahan L. The economic cost and psychological impact of musculoskeletal conditions. Arthritis Rheum 1995; 38: 11351-11362.
  13. van der Horst, Bruinsma IE, Speyer I, Visser H et al. Diagnosis and course of early-onset arthritis: results of a special early arthritis clinic compares to routine patient care. Br J Rheumatol 1998: 37: 1084-88.
  14. Lard LR, Visser H, Speyer I et al. Early versus delayed treatment in patients with recent onset rheumatoid arthritis: comparison of two cohorts who received different treatment strategies. Am J Med 2001; 111: 446-451.
  15. American college of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis. Arthritis Rheum 2002; 46: 328-346.
  16. Mottonen T, Hannonen P, Korpels M et al. Delay to institution of therapy and induction of remission using single-drug or combination-disease-modifying antirheumatic drug therapy in early rheumatoid arthritis. Arthritis Rheum 2002; 46: 894-898.
  17. Munro R, Hampson R, McEntegart A et al. Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study. Ann Rheum Dis 1998; 57:88-93.
  18. Tsakonas E, Fitzgerald AA, Fitzcharles MA et al;. Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3 year follow-up on the hydroxychloroquine in early rheumatoid arthritis (HERA) study. J Rheumatol 2000; 27: 623-629.
  19. Egsmose C, Lund B, Borg G et al. Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5 year follow up of a prospective double blind placebo controlled study. J Rheumatol 1995; 22: 2208-13.
  20. Bukhari MAS, Wiles NJ, Lunt M et al. Influence of disease-modifying therapy on radiographic outcome at 5 years: results from a large observational inception study. Arthritis Rheum 2003; 48: 46-53.