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Medicine Matters rheumatology

Hello, and welcome to this Medicine Matters rheumatology podcast. On World Arthritis Day, we spoke with President-Elect of EULAR Professor Iain McInnes, about the importance of early diagnosis and treatment of rheumatic diseases.

We have very good evidence that the earlier we start medical therapy, the more likely that therapy is to be effective. Not only that but the magnitude of response, the depth of response is likely to be greater if we start at an early stage. We don’t fully understand that but it has its origins at least in part in preventing damage, and in the rheumatic musculoskeletal diseases damage is very closely related to loss of function and disability and a very useful way of thinking about this is to consider that function lost is very difficult to regain, and so the earlier we intervene, the earlier we restore function to people who have been affected by these dreadful diseases, the more likely we are to give them a long term improved outcome.

What happens if treatment is delayed, what are the consequences for disease progression?

One of the central tenets of thinking in the last decade has been the idea of a window of opportunity in the treatment of inflammatory arthritis especially, and that is the concept that there is a period of time where inflammation can be targeted, when long term remission can still be achieved, that is the immunological response and the tissue damage that occurs, is still in a reversible state, such that homeostasis in tissue, and potentially even therefore drug-free remission could become reasonable and achievable targets.

There is very good evidence from inception cohort studies, and also from early arthritis intervention trials that a window of opportunity probably does exist, it hasn’t been pathologically defined but at least at the clinical concept level most people would accept that that early period of intervention gives us the opportunity for better outcome. What is also absolutely clear is that once damage is done to the musculoskeletal system, we are not yet in a position to offer reparative therapy beyond joint replacement, and for a very, very large number of the  joints that are affected by inflammatory arthritis, joint replacement is simply not a feasible or reasonable option. So the consequences of delay are, of tissue damage, cartilage and bone erosion, loss of function, and with loss of function comes the very direct proportional impact of quality of life.

What impact does this have on a patient’s quality of life?

Now, one of the things we’re recognising about delayed diagnosis is the very substantial adverse impact that has on long term maintenance of function, participation in work, presenteeism and absenteeism are major issues for people with RMDs. The interactions with family, with friends, social relationships, personal relationships, and also increasingly recognition of diminution of self-esteem, and with that, cognitive and psychological decline.

Comorbidities can occur in people with inflammatory arthritis – is this affected by a delay in diagnosis?

Delay in diagnosis leads to an increased comorbid burden, and also the occurrence of so-called multimorbidity, defined as the presence of two coincident long-term conditions in an individual. And multimorbidity in itself confers poorer outcome, higher risk of polypharmacy, and in the long term even reduced life expectancy.

These comorbidities include, for example cardiovascular disease risk, osteoporotic risk, increased risk of depression and cognitive dysfunction, and many of these in turn are driven by the inflammatory pathways that are also targeting the joint. So taking all of that together, delay in diagnosis confers a very much poorer long-term outcome for the individuals affected, and for that reason is something that we’re really very concerned about in people.

Are there any tools available for primary care physicians, to assess who may be at risk for developing a rheumatic disease, in order to ensure earlier referral and diagnosis?

Well this is an excellent question. I think at present there are no universally adopted and validated tools that can be used in primary care or even in the community. That is not to say that not a large number of often questionnaires, and now increasingly the use of apps, public awareness and publicity campaigns, health fairs and the like, at which the presence of musculoskeletal symptoms are being flagged up, and as a consequence referral is being encouraged. In some respects, this is one of our areas of unmet need. We desperately need to have available to us, and particularly to our colleagues in primary care, better means of identifying those patients in whom musculoskeletal symptoms are in fact a signal that there is an underlying inflammatory condition which will benefit most from urgent referral and then intervention, following appropriate evaluation.

Could more be done to raise public awareness of rheumatic musculoskeletal diseases and the recognition of symptoms?

With respect to the community, this in an area for example that PARE, the patient arm of EULAR have been working very hard on raising awareness, and in fact part of the solution here is in fact bringing a degree of education to the general population, such that when one is thinking about the risks to one’s health and one is thinking about very obvious concerns about cardiovascular risk, bone health, risks of cancer, that we begin to raise awareness that in fact the musculoskeletal system is also something that we should be giving attention to, and at the early onset of symptoms would prompt us to go and look for help. And I think that’s a level of awareness that has not been present in the general population in years gone by.

What campaigns are EULAR running to help raise this level of awareness?

Well, Don’t Delay, Connect Today is just the most exciting programme you can imagine! It’s a direct response that we have had in EULAR to the need for us to raise awareness of the importance of the very early recognition, referral and treatment of people with arthritis. Don’t Delay, Connect today is a pan-European, and we hope in fact a global campaign that is driven by public awareness being heightened as to the real importance of early evaluation of musculoskeletal symptoms.

It is very much a patient-led initiative, and I must commend the work of PARE, as I say a EULAR patient arm who have really pioneered publicity events, launch events, in several different countries in Europe to very great effect, and as a consequence there is an increasing awareness both in the general public and in key stakeholders, healthcare providers and politicians, and other similar parties, that very early recognition of arthritis confirms substantial long-term benefits. Don’t Delay, Connect Today says it all. If you have musculoskeletal symptoms, we’d like to see you, we’d like to evaluate, and we would like to then intervene if that is both appropriate and likely to bring about long term benefit.

Finally, what does the future look like for patients with these diseases and the clinicians treating them?

The last decade for rheumatologists have been quite the most exciting. I think it’s fair to say that twenty years ago, musculoskeletal disease was not considered a healthcare priority. The medicines that we had available to us were very often toxic, and of only partial value in the clinic. And we also were handicapped by strategic approaches to the treatment of disease which were the inverse of what we would now consider to be optimal. That is, we waited in a so-called therapeutic pyramid for patients to become damaged before we would initiate therapy.

What we’ve seen in the last 10-15 years is an absolute transformation in the opportunities that we have to treat our patients. And so we now have new, exciting modes of action, therapeutics that are often highly effective, and we’ve learned that the way in which these therapeutics are used, the core strategies of care, should be predominantly early aggressive intervention, and treatment to a target, that is, we’re setting ourselves the goal of reaching low disease activity, or indeed remission. And those two things together, innovative new therapeutics and innovative new strategic approaches have transformed the lives of millions of patients so far.

But by no means are we complacent. There are still significant unmet needs. We don’t have nearly enough patients in remission. And so the future, I think is even more exciting. We’re going to bring the power of molecular medicine and a really heightened awareness of the importance of the rheumatic musculoskeletal diseases at the European, and indeed the global level. And with that we can look to improve the quality of life of our patients even more in the years to come. A really exciting time.

So, early diagnosis and treatment of rheumatic and musculoskeletal diseases can result in improved function and quality of life, reduced comorbidities, and an overall better long-term outcome for these patients. There is a need for validated tools to enable earlier referral by primary care physicians, but public health awareness campaigns such as Don’t Delay, Connect Today are improving early recognition of these diseases. Thank you very much to Professor McInnes for sharing his thoughts on this topic.