VIDEO: Challenges in rheumatoid arthritis management

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The diagnostic challenges in rheumatoid arthritis are primarily when you think about defining the early stages of the disease, because the early sign and symptoms of rheumatoid arthritis can mimic those from other diseases. And we really do not have a blood test or a physical finding that is very specific to confirm the diagnosis in the early stages of the disease. Of course, when deformities set in, you know, it's much easier to say someone has a rheumatoid arthritis. We also struggle with how to monitor patients. You know, while typically we see patients with rheumatoid arthritis every three to four to six months, depending on their stage of disease, we really have no idea if perhaps we should visit with them more frequently because we don't have good biomarkers as to who's going to progress more rapidly or who is not. We also need more research to be done on biomarkers, for what medications to initiate, and also perhaps with the advent of digital health, that can help us monitor patients a little bit better because it's not going to be just visits in clinic, but also in between clinic visits that can provide information on symptoms, on disease activity, and that may make us more able to make informed decisions about changing medications.

Another management challenge in rheumatoid arthritis is about tapering medications that we use. We know how to start medications. Maybe we don't have the biomarkers to help us to decide exactly what medications, but say we start a biological disease modifying agent. When a patient is doing well for a long period of time, frequently they want to know, "Can I come off medication?" And that's a difficult decision. It's a very personal decision. And several studies have been done over years trying to answer the question, "Should you stop abruptly? Should you taper the medications? What's the best approach? How much time the patient should have been in remission before the patient could consider in collaboration with their physician to discontinue or taper a medication?"

Another topic of interest is related to use of corticosteroids, a medication class that we have loved to hate, so to speak, because it really works well to treat flares, but it has so many consequential side effects. And we're still in the sort of what I call infancy of how to use corticosteroids in rheumatoid arthritis. In fact, in any of our diseases in rheumatology. Because you know the right tapering schedule, right route of administration, there are many ways of doing that, using corticosteroids, and we don't know which one is better than others. So for example, if we were to give an intramuscular corticosteroid preparation in clinic for a flare, is that better than giving a short course of oral corticosteroid at home for that patient who flares?