Q&A: Early detection of rheumatoid arthritis is vital in young adults
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Katherine Terracina, MD, an assistant professor of rheumatology with McGovern Medical School at UTHealth Houston, spoke with Healio about rheumatoid arthritis in young adults and how early detection from a primary care physician is vital for the best possible treatments.
Healio: When should primary care physicians suspect and subsequently refer young adult patients with RA to specialists?
Terracina: RA is a peripheral symmetric inflammatory arthritis. This means it is type of arthritis that affects the joints of the limbs or extremities. Often, it is on both sides of the body in three or more joints, and the symptoms persist for more than six weeks.
A big thing for PCPs to think about when a patient presents with joint pain is if the pain is inflammatory in nature. This means that a patient is reporting joint pain that is worse in the morning, with stiffness that lasts more than 30 minutes, and pain that gets better with activity. If the patient sits for a while, the pain might come back and improve again once they are moving. This helps contrast against mechanical arthritis which we get with age, overuse or certain injuries. Mechanical joint pain usually comes with activity and improves with rest. That's the main way we differentiate inflammatory versus wear-and-tear arthritis.
A PCP can also screen for other things: Does the patient have psoriasis? Does the patient have inflammatory bowel symptoms? Do they have a history of uveitis? If the answer is yes to any of these questions, they should consider different types of inflammatory arthritis like spondyloarthritis.
If the PCP does suspect RA, they can start the work up by ordering inflammatory markers (ESR, CRP), rheumatoid factor, anti-cyclic citrullinated peptide, and even X-ray of the hands, feet, or whatever joint might be involved. Once they have done this, I would recommend referring to a rheumatologist because the treatment can be very complicated with high-risk medications.
Healio: How does RA diagnosis and treatment differ between women and men?
Terracina: RA is more common in women, usually younger women. There’s really no difference between the classification criteria in men versus women. Patients should always describe the same peripheral symmetric polyarthritis that's inflammatory in nature. There are some studies that say women may have higher clinical disease activities where it may be more severe or affect their life a little bit more. We're not exactly sure why that is — some thoughts are that men have greater muscle mass that can help compensate for the arthritis better.
The big differences comes down to treatment options. If a woman is in childbearing age and thinking about family planning, treatment is approached differently.
Healio: In treating young patients with RA, how does disease management look (treatment options, shared decision-making, transition to adult care)?
Terracina: There are many treatment options in RA. Finding the right medication for a patient is not just finding a medication that helps their disease, but also finding one that is safe for them.
Having a good working relationship, open communication, and honesty with the patient is extremely important. These medications can be very scary. If a woman is of childbearing age and interested in having a family in the near future, I'm going to make sure I use medications that are safe in pregnancy. Certain medications can be teratogenic, meaning they don't make a woman less fertile, but they can cause serious harm to baby.
Other factors I consider are if a patient travels a lot for work or doesn't have a secure housing situation. In these situations, I might avoid medications that require refrigeration. If a patient drinks alcohol frequently, I need them to be honest with me because certain medications can cause damage to the liver.
Cost of medication is also huge. Many of the medications to treat RA are not cheap. As a provider, I typically don’t know how much a patient is going to be charged for certain medications. I don't want to make a patient choose between buying dinner and taking their medicines. If we can work together on finding medications that are affordable for them with their insurance, then we will have much better adherence to the medications.
Again, it's really having that open conversation, honesty, and working together to find a regimen that work.
Healio: How does early detection of RA differ from a later diagnosis? Can RA in young adults affect their overall lifespan?
Terracina: The earlier we detect RA, the better. We have great treatment options now. Every few years, we have new medications that we can use to treat RA. If we can diagnose early and get patients started on treatment sooner, we're often able to prevent deformities and permanent disabilities that come with long-standing, untreated arthritis.
Unlike some types of arthritis, RA needs to be treated with disease-modifying anti-rheumatic agents (DMARDs). Just treating with an over-the-counter anti-inflammatory is not going to stop progression, disease, or deformity. If we can diagnose early and get patients started on treatment early, it is going to greatly help put the disease into remission.
Early detection can also affect other complications of RA such as heart disease that can come from long-standing active inflammation. We often think about patients with RA having a little bit shorter life expectancy, but a lot of that comes down to uncontrolled or long-standing inflammation. As long as RA is treated, patients can go on to live normal lives.
Healio: What additional health risks could a younger diagnosis of RA infer?
Terracina: RA can affect long-term health. It increases the risk for cardiovascular disease, it is an independent risk factor for osteoporosis, and it affects the immune system so there’s an increased risk for infections and possibly cancers. The longer someone has RA, the higher risk they may have for some of these complications.
With infections and malignancies, there is an inherent risk with RA alone, but some of the risk is augmented by some of our medications. We use immunosuppressive agents, so patients do have a little higher risk for certain infections, especially atypical infections. There is also a slight increased risk with malignancies with some of our treatments, but by finding the diagnosis early and being on treatment, we know to monitor for this.
It is also important to point out that RA doesn't go away. You can't be cured at this point. RA can go into remission, but patients often need life-long treatment. Because of this, the patient’s sense of self is likely going to be altered by now living with a chronic disease. Fears such as will they develop a chronic disability, will they be able to keep working, will they be able to afford their medications are all very common. This can lead to depression or just change how they perceive themselves. Therefore, in addition to treating the arthritis, it is really important to focus on mental well-being and discuss this with their physician
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