Meeting the Challenges Ahead in Rheumatology

The demands of the practice environment have been expanding in many ways, as patient needs become both more clear and more complex.

According to Meenakshi Jolly, MD, MS, director of the Rush Lupus Clinic, Rush University Medical Center in Chicago, IL, “the biggest change in clinical rheumatology practice is a focus on a multidisciplinary approach for management of chronic autoimmune diseases, using the biopsychosocial model of health. Empowering the patient and managing the disease in context of the patient’s internal and external resources and health beliefs are important to maximizing benefits of any medical intervention.”

While the expanding range of novel therapies for rheumatologic diseases offers new hope for many patients, it’s still a long road to help every patient find relief from pain and symptoms.

“A number of new targeted biological therapies and targeted synthetic DMARDs are now available for the treatment of RA, psoriatic arthritis, and ankylosing spondylitis,” said Clifton O. Bingham III, MD, director of the Johns Hopkins Arthritis Center at the Johns Hopkins University School of Medicine in Baltimore, MD. “Even with these, there remains a need for additional options for patients who fail to respond. Fortunately, there are a number of ongoing clinical trials of new agents across these disease areas, some with similar and some with novel therapeutic targets.”

The current insurance system severely limits what clinicians can use to treat their patients.

Arthur M. Mandelin II, MD, PhD, RMSK, RhMSUS, associate professor of medicine, Northwestern University Feinberg School of Medicine in Chicago, IL, and practicing rheumatologist in the Division of Rheumatology, expressed his frustration this way: “I think the one biggest issue in 2019 would have to be our ongoing challenges with insurance coverage. Many of the drugs used to treat arthritis are expensive, and insurance companies are always throwing up roadblocks to their use. The most annoying part is that well over 90% of the appeals we file eventually get approved in the end, so most of these roadblocks turn out to simply be a waste of everyone’s time and effort, and a needless delay of treatment for the patient.”

Ailda Nika, MD, assistant professor in the Division of Rheumatology at Rush University Medical Center and a rheumatologist at Rush Medical Center in Chicago voiced similar concerns: “For patients with chronic diseases, especially the ones like lupus that may have unpredictable flares and affect young women, there is an obvious unmet need for educational, emotional, and social support. However, these resources are not available to patients due to poor coverage of mental health by insurance.”

Our experts expressed a frustration with the limitations of current therapies that fall short of curing or arresting rheumatologic diseases.

According to Dr. Jolly, “From a treating physician standpoint, major challenges pertain to lack of prevention or cure for our diseases, and the increasing comorbidity burdens like death from cardiovascular diseases in autoimmune diseases such as SLE and RA. Ongoing inflammation contributes to increased risk of CVD in our patients, yet in SLE we do not have very many options of safe but effective medications to treat the condition.”

Dr. Mandelin reported a similar challenge to finding the right therapy, given the many emerging DMARDs. “The sad fact is that the treatment failure rate in RA, for example, remains dismally high, and thus many patients have to suffer through a time-consuming trial-and-error process before they find the best drug for them through chance alone. We dream of a day when we can somehow test the patient at the outset and learn the correct mechanism of action to target in that particular patient. Since blood testing has so far failed us in this regard, some efforts are now beginning to focus on the target tissue itself, the synovium.”

Dr. Nika expressed frustration about lack of basic understanding of the mechanisms of rheumatologic diseases like SLE. “While fatigue remains one of the most common issues faced by lupus patients, we still do not have full understanding of the causes and management of this symptom.”

Dr. Jolly, who is director of the Lupus Clinic at Rush University Medical Center, focused on the challenges of conducting research to improve outcomes: “To get clean results from SLE clinical trials we need to limit the medications that the patients get as standard of care, as they may confound the results. However, withholding medications may not be optimal or safe for our SLE patients.”