Sequencing of Therapy for Rheumatoid Arthritis - Episode 10

Risk Factors and Clinical Burden for RA

Stanley B. Cohen, MD: What we talked about are the various factors such as seropositivity or elevated acute phase reactors, which predict the course for rheumatoid arthritis. We know that if a patient already has x-ray changes, they’re more likely to have future x-ray changes. So, those are risk factors that usually predict outcomes for rheumatoid arthritis, other than being a family member—a sibling, a brother or sister—of someone with rheumatoid arthritis, where your risk is modestly increased; the risk is doubled. If the normal risk of having rheumatoid arthritis is 1 in 1000, per se, then having family members doubles that risk to 2 in 1000. So, the risk is still very low.

In the old days, 30 or 40 years ago, rheumatoid arthritis was diagnosed by primary care physicians and managed by primary care physicians. It’s now far too complicated, and these patients are generally under the care of a rheumatologist, unless they’re in an area of the country that’s underserved. Many of our rural areas in this country—places like Wyoming, North Dakota, and so forth—have very few rheumatologists, and the PCP will have to manage the patient the best they can. But our therapies and our approach are to be aggressive early on, to use combination therapies and potentially biologic therapies. These areas are really out of the realm of the PCP at this point—most PCPs, unless they have a special interest in our diseases. So, for rheumatoid arthritis, if you have that disease, you should be under the care of a rheumatologist who works together with the PCP on the management of the patient.

Rheumatoid arthritis, we believe, affects about 2 million to 3 million people in North America. It’s about 1% of the population that we have. It is a disease that has significant burden from a socioeconomic status standpoint, but it has improved tremendously however, with our therapies and our aggressive approach. But many of these patients are unable to work, are unable to function in their daily activities, or have limitations. Our therapies to manage the disease are extremely expensive—the biologic therapies. On the other hand, they’re incredibly effective, and it’s much more fun to be a rheumatologist now than it used to be.

We basically shifted the cost from hospitalizations, which were the primary drivers of cost in the 70s and 80s and 90s, to the therapies now. Patients with rheumatoid arthritis are having much less joint surgery—total hip replacements, total knee replacements, hand surgery—but still, the cost is up, and the burden on the patient, just from an inability to be a wage-gainer, is because of the persistent active inflammation that they might have.

There is no question that we have limitations due to cost as far as managing our patients. Unfortunately, in this day and age, the decisions we make are often resisted by insurance companies who are unwilling to pay for our expensive drugs, or have what we call step edits, where we have to go through what they feel is appropriate for the patient or how we treat them. We have a number of patients who are underinsured and cannot afford the copay that they’re required to pay for their therapies or their visits. And so, there’s no question that cost does play a role.