Board Members Reflect on Past 10 Years of Rheumatology

In the 1980s, I became impressed that the traditional therapeutic pyramid offered "too-little and too-late" therapy to prevent tissue damage. It was for this reason, based on personal observations of therapy for rheumatoid arthritis, that we published an editorial: (Wilske and Healey: "Remodeling the Pyramid – A Concept Whose Time Has Come" [J. Rheumatol. 1989;16:565-7]). This therapeutic change was based on the concept of controlling inflammation early, before tissue damage occurs, and then stepping down to less-toxic and less-expensive drugs to maintain control of inflammation. Initially, with the traditional therapeutic pyramid, rheumatologists and health care workers were satisfied with a 20% improvement. With the new concept of early therapy to control inflammation, they now require 80%-90% improvement and are even looking at the possibility of a remission.

Until a cure is achieved, requiring a more detailed knowledge of the inflammatory process, continued improvement in therapy will require early therapy before tissue damage. The best definition of "early" may be when the rheumatoid factor and citrillated proteins turn positive, before clinical symptoms are noticed.

Kenneth R. Wilske, M.D.

Clinical Professor of Rheumatology, University of Washington, Seattle

Beware the Treatment Algorithm

The past 10 years have seen a number of changes in rheumatology. The armamentarium of therapeutic options to treat our common and not-so-common diseases has expanded, and the promise of understanding disease pathogenesis translating into better therapies has been realized. Ten years ago, "biologics" were in their infancy, limited to TNF inhibitors, proven at that point to be most effective for rheumatoid arthritis. Since that time, the use of this class of medication has expanded to other inflammatory arthridities and even nonarthritic rheumatic diseases (such as inflammatory eye disease and Behçet’s). Moreover, other "biologics" have been developed including co-stimulatory molecule blockers, B-cell–depleting therapies, anti-B cell strategies, and IL-6 inhibitors. Other therapies that are in development hold promise in a number of inflammatory rheumatic diseases.

Another important development in the past decade is the improved ability of the rheumatologic community to conduct clinical trials with meaningful measurable outcomes in uncommon disorders. There has been a proliferation of carefully conducted vigorous clinical trials in scleroderma, vasculitis, and systemic lupus. Indeed, the rigor and size of these trials were adequately robust to justify FDA approval for therapies in vasculitis and in systemic lupus. Some of this success relates to the clinical investigative community’s better ability to define outcomes of relevance for clinical trials, as well as the increased enthusiasm for collaborative cooperation among clinical investigators in relatively rare disorders which require multicenter efforts.

Along with these encouraging advances in translational science and better organization of clinical trials, the past decade has seen some trends in rheumatology that could be worrisome. One major change is the institution of electronic medical records. Although this is an inevitability and holds the promise of better efficiency, to date, the implementation of EMR often results in "templates" used in the evaluation and management of rheumatic diseases that are conditions wholly unsuited to the use of such templates. The narrative is an integral part of understanding the diagnosis and impact of disease in rheumatology, and it seems that clinicians being pigeonholed into these templates may compromise the appreciation of the subtleties that often are requisite to arrive at a diagnosis of rheumatic disease, particularly when presenting in an atypical form.

The use of outcome measures defined by insurers as the determinants of efficacy of therapy similarly poses real risks in managing patients with rheumatic diseases. Even the recent enthusiasm for "Treat to Target" has ignored the reality that the targets chosen may not have been proven important in clinical practice. Indeed, some of the specifics of those measures have changed over the past years, but we cling to having quantifiable measures that may not incorporate either the art of clinical medicine or the importance of patient-centered outcomes in caring for patients with chronic diseases. A concern is that the management of rheumatic diseases will become algorithmic, and the nature of these diseases is not suited to such an approach.

Nevertheless, these efforts hold promise in ensuring an adequate level of care in a broader manner for patients with rheumatic diseases. The dialectic between the art of medicine and the narrative of the patient’s story, and the use of quantifiable outcomes will undoubtedly evolve in the coming years and, I hope, will incorporate both factors into the final disease measures that we use to assess the efficacy of therapies in the future.

Robert Spiera, M.D.

Director of the Vasculitis and Scleroderma Program at the Hospital for Special Surgery in New York