Senior Physicians Speaker Series : What ’ s New in Rheumatology ?
Dr . Sam Yared , Senior Physicians Speaker Series Chair , introduced Dr . Gary Crump , co-founder of Rheumatology Associates , PLLC , on Tues . April 2 . The Louisville native is a graduate of the UofL School of Medicine and did his residency in internal medicine and fellowship in rheumatology at the University of Cincinnati . He served as the Laboratory Director of his practice ’ s COLA-certified lab for 20 years .
Rheumatoid Arthritis ( RA ) is the most common autoimmune inflammatory arthritis in adults . Often insidious in onset , it can have systemic manifestations before presenting with joint inflammation and swelling . It has an annual incidence of about 40 per 100,000 and women are affected two to three times more often than men . RA can occur at any age , but peak onset is between ages 50-75 .
Established RA is defined as having been present for at least six months , and it is believed that most patients have had the autoimmune process for a year or up to a decade before the disease clinically declares itself .
Even in the last 30-40 years since Dr . Crump started training and practicing , he said there has been a very dramatic change in the field . While waiting rooms were previously filled with braces and wheelchairs , much progress has been made , leading to better medications and patient outcomes . Treatment goals are threefold : 1 ) treating the signs and symptoms , making the joints not stiff or painful , 2 ) improving physical function , and 3 ) preventing structural damage . One must also consider preventing the systemic complications , like interstitial lung disease and inflammatory eye disease , that come with uncontrolled chronic inflammation . A new algorithm called Treat to Target ( T2T ) has been demonstrated in multiple trials to result in better outcomes for patients than conventional treatment .
Since the late 90s and the first class of biologics used as targeted therapy for RA , TNF inhibitors , we now also have a T-cell co-stimulation inhibitor , IL-6 inhibitors , JAK inhibitors and B-cell depletion ( less use since COVID-19 , as it tends to deplete antibodies ). In
28 LOUISVILLE MEDICINE by KATHRYN VANCE terms of precision medicine , there is a new test called Prism RA that gives a 90 % probability of whether or not a patient will respond to a TNF inhibitor .
Psoriatic Arthritis ( PsA ) looks a lot like RA , and it can be hard to tell the two apart . Most of the time , the patient has cutaneous psoriasis before or at the time they get inflammatory arthritis . Diagnosis is based on clinical criteria , as there is no serologic marker . Some associations of PsA include inflammatory bowel disease and inflammatory eye diseases such as iritis . This one is a part of the spondyloarthropathy family of diseases .
PsA is thought to express itself clinically in a variety of ways , a bit different than RA . Genetics play a part , but also environmental factors such as smoking , possible infectious agents and physical trauma . There are many outcome measures for PsA , but MDA ( minimal disease activity ) is becoming the best method , he said .
There are some very good treatments that work well for PsA that target specific cytokines which aren ’ t particularly useful in RA . While exact treatments between the two are quite different , the strategy remains the same . They measure the disease activity using the MDA , which is an aggregate of multiple domains . Treatments include DMARDS ( like MTX ), oral small-molecule entities ( apremolast-PDE-4i ), biologics : TNFi , IL-17i , IL-23i and oral JAKi .
As with all treatments , there are risks involved . From autoimmune diseases like lupus or MS , to liver and hematologic toxicity , there is a lot of room for customization of treatment to a particular patient ’ s underlying comorbidities . To manage RA and PsA , both complex systemic illnesses , a collaborative effort across disciplines is essential to manage symptoms optimally .
This is a summary of the Senior Physicians Speaker Series presentation . For a link to view the full presentation , please email foundation @ glms . org .
Kathryn Vance is the Communications and Event Coordinator at the Greater Louisville Medical Society .