The goal of therapy in RA: LDA vs. remission, or perhaps the patient’s well-being
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This month, we are so lucky to have such an extraordinary panel of experts in the field of rheumatoid arthritis — Daniel Aletaha, MD, MSc; Stanley Cohen, MD; Bryant R. England, MD, PhD; Roy Fleischmann, MD; and Liana Fraenkel, MD, MPH — debate the merits of remission vs. low disease activity as the desired target in the therapy of rheumatoid arthritis.
Selecting too rigid a criterion for our goal sets up the risk for over treatment, while too lax of a goal risks ongoing structural damage. I can confidently say at the outset that all of these experts are extraordinary not only as clinicians but as healers as well, each recognizing and, I suspect, agreeing with my assertion that whatever target we select, the patient’s well-being must be at its center.
Let me also state the obvious — namely that our therapies today are extraordinary and, in general, we can quiet RA disease activity down, and keep it there, in the vast majority of cases. I also agree that better biomarkers are needed to tell us whether we have suppressed the disease optimally. On the other hand, in most of our disease activity scales that include the patient’s global assessment, each patient has the right to tell us they are not zero.
Maybe it’s not inflammation that is driving their pain, and thus we need to be skilled clinicians to critically appraise these cases. Maybe they are bothered more by lack of sleep or fatigue, or numerous other symptoms not accounted for in virtually all disease metrics.
As we have discussed in the past, I strongly favor the imperative of a dual target (“Pursuing the ‘obvious ethical imperative’ of a dual target approach,” published March 17, 2021, on Healio). In this model, the patient as a person is elevated at determining when and why they are not satisfied with their state of well-being. Yes, it is more complex than calculating a CDAI or a RAPID-3, but our skill and willingness to sort out not only our patient’s chief complaint of the day, but also their chief concern, is vital to their health and well-being.
There is a move afoot internationally to codify and endorse such an approach, and I will tell you that it will require a reorientation of sorts in our training programs. We will need to not only emphasize the science of disease and their therapies but also refocus on advances in communication skills and practitioner-patient relationship building.
These skills are often assumed as byproducts of medical school training and residency, but in reality they vary greatly among clinicians. Advanced training in empathic communication, relationship building, and the science of placebo are rarely formally taught in rheumatology fellowship programs, I suspect. These latter skills are powerful tools to enhance the care model and have been demonstrated to not only improve patient satisfaction, but also hold the potential to relieve symptoms such as pain and fatigue independently from modifying the pathophysiology of the disease.
If this is true or even possibly true, it merits a pivot in our research, which must expand from a disease-centered model as well as expand to accommodate more person-centered research. I tweet (@LCalabreseDO) about the science of #empathy a lot and love to hear from people on their perspective and experience. If your fellowship program is engaged in formal teaching and research in the skills I am referring to, I would love to hear from you. Share your thoughts with us at calabrl@ccf.org or at rheumatology@healio.com.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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