Michael E. Weinblatt, MD
Rheumatoid arthritis is a chronic inflammatory disease that affects about 0.7 percent of the population. It’s a disease that affects young people, so it begins at age 20 to 30 to 40 years of age but it can occur at any age. So we see it in children, juvenile idiopathic arthritis, and we see it in our senior citizens. And its marked by an inflammatory reaction in the joints, which untreated can lead to joint destruction. It’s a systemic disease, it’s a generalized illness so it’s not just a disease of the joint but it can be a disease of multiple target organs, including the lung, the heart etc.
Most patients with rheumatoid arthritis have involvement initially of their joints. I’d say probably 95 percent of patients will present with an actual arthritis, because that’s the primary focus. About 10 to 20 percent of patients with rheumatoid arthritis will also go on to develop what’s called extra-articular, that is disease besides just the joint. The most common manifestations would be dry eyes and dry mouth. Some patients can present with that first and then go on to develop arthritis.
It’s a disease that we don’t cure, so patients with the disease may have it for multiple decades. It affects women, three times more commonly than men, there are genetic factors that associated with the illness, and the prevalence rates appear to be fairly constant. There are some studies that suggest that the rates of rheumatoid arthritis are diminishing due to reduction in some of the factors associated with the illness, but there are other studies that say the prevalence rates remain about the same.
The risk of untreated disease that we can all appreciate is significant: destruction of the joint, disability, inability to work, inability to do the activities like run marathons or ski for some people. And very significant rheumatoid arthritis increases the risk of heart disease by two to three fold and can decrease your life survival. So that has to be weighed with the drugs, and these drugs are good but there are some side effects associated with them.
The major drug we use is methotrexate, we’ve got thirty years of clinical experience with the drug. The most common reason why people stop methotrexate due to a side effect is not due to serious side effects but due to nuisance side effects, which is primarily nausea.
Rheumatoid arthritis management is really a team approach. A patient needs a primary care doctor, and needs a specialist whose well aware about the drugs that we administer in the disease course. The primary care doctor is essential because, as I mentioned, patients with rheumatoid arthritis have an increased risk of heart disease, we need the primary doctor involved to manage the cardiovascular risk factors, we also need them involved to manage their general medical care. Patients with rheumatoid arthritis may be at an increased risk of not just heart disease but other serious illnesses including malignancy, so screening is important, and they need to be a part of the team in monitoring the drugs, because of drug toxicities.
The rheumatologist needs to be involved because the drugs that we use are fairly complex, they have unique side effects. We basically tailor the treatment based upon the individual patient. There’s no basic template you can use on how we should manage each patient. It’s individualized based upon the age of the patient, their occupation, what their background medical history is, what they’re doing, what their expectations are. If they’re a young woman, are they interested in conception? These are all issues that we deal with in the individual patient. And additionally, the rheumatologist needs to be involved, because as I mentioned, it may not just be the joint that’s involved, there may be other organs involved in the treatment course.
We don’t know what causes rheumatoid arthritis, a lot of the work at the Brigham and Women’s Hospital is looking at what causes the disease. It’s felt that it’s probably an outside or internal insult in a patient that has the right, or in this case wrong, genetic profile. Our goal in treatment is to reduce the inflammatory reaction. So our primary focus is treat people once they actually present with the arthritis. Our clinical research group, my laboratory, has been interested in looking at new therapies, for the disease, we began in 1982, studying this anticancer drug, methotrexate, which was and is currently used at high doses to treat a variety of malignancies. We’ve been using it at a low weekly dose, one one-hundredth of a dose used in most cancer therapy regimens and in about 60 to 70 percent of patients there’s a very positive response. Additionally, we’ve been studying these biologic response modifiers, drugs that block a substance called tumor necrosis factor, drugs that block other mediators such as interleukin 6, block the reaction between the lymphocytes that lead to immune response, for instance, as well as oral molecules, and these drugs have also really enhanced our ability to treat the disease.
We also have here a large patient registry called BRASS, which stands for Brigham Rheumatoid Arthritis Sequential Study, and I work with my colleague Nancy Shadick, on this registry. We’re now into year thirteen of the registry. It serves as a biorepository and clinical database. We have 1400 patients enrolled that we’ve been following to collect samples annually and we collect an intensive clinical data base so that clinical researchers from around the world can examine this and look at various questions, as well as to obtain laboratory samples to further their research.
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