From Rheumatism to RA: A Basic Change in Understanding

"Doc Gumshoe" Looks at Rheumatoid Arthritis

By Michael Jorrin, "Doc Gumshoe", October 31, 2013

[ed note: Another piece from “Doc Gumshoe” today — Michael Jorrin is not a doctor, he’s a longtime medical writer who we love because he explains diseases, treatments, and health controversies in a way that makes sense. The words and opinions shared below are his alone. If you’re curious about whether rheumatoid arthritis matters to folks who don’t have it, consider that it’s a very widespread disease (roughly half of one percent of US adults have it), and the treatment thereof is a major focus of pharma companies — Humira, the best-selling RA drug, generates sales of more than a billion dollars per quarter (and climbing)]

What we’re looking at here is not just incremental progress in the treatment of a medical condition, but a fundamental change in the way this condition is understood in every aspect, from its impact on the patient to the way it’s managed to the expectations, on the part both of clinicians and patients, for patient outcomes. What has happened in the overall perception of rheumatoid arthritis in the past 30 years is an example of what can happen in disease management when things go right.

Turning the clock back, let’s consider what was meant by “rheumatism” for many, many years, right up to the second half of the 20th century. Rheumatism was accepted as a common condition that affected mostly the elderly. It was characterized by fluid – “rheum” – in the joints. It caused pain, swelling, stiffness, and, ultimately, resulted in decreasing mobility. Old folks with rheumatism commonly hobbled about with canes and sometimes were confined to wheelchairs. There wasn’t a whole lot that could be done about it. Treatment was palliative, meaning that it was aimed at alleviating the worst of the symptoms. But palliative treatment was generally thought to be about as good as one could hope for, because, after all, nobody died from rheumatism.

Or did they? Starting in the 1980s, evidence began to trickle out that people with rheumatoid arthritis were at significantly increased risk of death compared with people of the same age in the general population. A rheumatologist named Theodore Pincus caused a considerable stir at a meeting of the American College of Rheumatology (ACR) in 1984 when he reported that in a group of 75 patients with RA who had been tracked for 9 years, the mortality rate was about the same as in patients with heart disease blocking three coronary arteries – i.e., really severe disease. By the mid 1990s, there were lots of data showing that, in fact, rheumatoid arthritis did kill people – or, at least, that patients with rheumatoid arthritis were more than twice as likely to die as people of the same age in the general population.

Exactly why this is nobody can say for sure. Without question, there are comorbidities with rheumatoid arthritis – cardiovascular disease, infections, diabetes, malignancies – but to what extent the underlying rheumatoid arthritis causes or merely contributes to these comorbidities is uncertain. However, one factor that cannot be underestimated is the lack of activity that is imposed on many patients with RA.

But what became certain was that RA could not be considered a “benign” condition, with treatment focused only on managing the symptoms while ignoring the underlying progression of the disease.

What is the impact of rheumatoid arthritis?

Compared to osteoarthritis, rheumatoid arthritis is relatively uncommon. It’s estimated that about 50 million Americans have some sort of osteoarthritis, but only about 1.5 million adults in the US have rheumatoid arthritis. Another 300,000 young people have a form termed juvenile rheumatoid arthritis, which is of great concern. Usually, RA starts in mid-life or even later, but it’s by no means uncommon for people in their 30s to develop RA. This disease affects women about twice as often as it does men, and for unknown reasons, RA in younger women progresses faster than it does in most other cohorts of patients.

The symptoms of RA first appear in the joints. Rheumatologists (the physicians that study RA, as well as a group of other diseases that have been classified as autoimmune – we’ll say something about that later on) have zeroed in on 28 joints that are typically affected by RA. Fourteen of these are the joints in the fingers and thumbs, and the other 14 joints include upper-body joints (wrists, elbows, and shoulders), and lower-body joints (hips, knees, ankles). The small joints in the hands are more diagnostic of RA