A Winning Season* Save
Fall is ahead and football season is here. This season only brings out my most competitive side. Winning is everything – in football and in medicine. To fail is objectionable, even cry-worthy, but it may also be motivating and humbling. Rheumatologists (Rheums) have a cherished relationship with the patients they have to advocate and care for. Their trust and copays sustain us.
I thought it would be worthwhile to take account of last season’s success in managing many a rheumatic foe. Thankfully, we Rheums have won more than not. Here is a listing of last year’s schedule of opponents and results – my take on wins and losses in rheumatology.
- Gout: WIN Rheum 14 – Gout 0. I could’ve won this one by a much wider margin, but I just don’t see enough gout. Why is that? I can diagnose it easily, prove the diagnosis by crystals or X-rays, manage the worst acute attacks or quell chronic chemical and metabolic derangements that drive gout. Yet, I see about 2-3 patients every 3 weeks. In contrast I manage 50 rheumatoids in the same span. RA affects 1.3 million and gout 8.3 million Americans. I can only assume this foe is afraid to play me or doesn’t like to travel to away games. Or maybe gout wants to play in a much easier league where they can conquer, ravage and call the shots against an unknowing and unprepared ER or primary care doc de jour. Although this is an easy win, I wish they would just “show up”.
- Lupus: WIN Rheum 27 – Lupus 13. I can beat lupus. Yet every time I say that and think that, lupus gets my scouting reports and throws me a curve or train-wreck, something that surprises or perturbs my time honored treatments. My plan is simple (HCQ for all, 5 mg prednisone for most) and complex (an arsenal of MTX, azathioprine, mycophenolate, and strategic use of IV cyclophosphamide or even rituximab) has led to way more successes than failures. But this year SLE was difficult. Playing its trickery on my patients - alveolar hemorrhage, cerebritis, hemolytic anemia, and lupus profundus. While my patients and I complain it’s just not fair – no flags were thrown and we just had to power through. And we did.
- Polymyalgia rheumatica: WIN Rheum 56 – PMR 3. I can’t remember the last time I lost to PMR. I think it was back in 2004 when I had a PMR/GCA patient who presented as an FUO with temps of 104F daily, an unexplained anemia, and 3 fold hepatic enzyme elevations. Of course this was in addition to the myalgias, stiffness, and high ESR/CRP/ferritin. Since then, these guys show up, looking sickly, impressive with weight loss, and big-time “algias”. But I just whiff them with 15 mg of prednisone and 2 days later these octogenarians are doing cart-wheels in the driveway and telling their neighbors what “studs” those Rheums are. I’m not worried if they get a new game or pull a rabbit out of their symptom hat – we have tocilizumab and a bunch of other biologics to squash them if need be. Trash talk is easy with PMR.
- Scleroderma: LOSS PSS 31 – Rheums 17. This year’s loss was not nearly as bad as years past. This year we figured out that MTX and DMARDs may help with morphea and localized forms of scleroderma. Time and past failures have made us better in avoiding renal crisis, GI complications and progressive interstitial lung disease. Nonetheless, this tight bunch keeps rolling out the calcinosis, renal sclerosis, digital ulcers and MSK complications for which we have few or no answers. But there may be hope in next year’s draft with the early and promising success of tocilzumab, fresolimumab (anti-TGF beta monoclonal antibody) and Resnumab (granted fast track status by the FDA). Until then my unproven, but steadfast approach to this microvascular disorder is low dose aspirin, low dose statins, and any dose vasodilator anti-hypertensive. You think I’m wrong? Get your own team, league and draft. I’ve asked many Rheums in the past, which would you rather care for: 1 case of progressive skin/renal/lung scleroderma or 10 recalcitrant fibromyalgias? No one volunteers to choose either – it’s too painful.
- Rheumatoid arthritis: WIN Rheums 56 – RA 39. This is my homecoming game, with a full marching kazoo band, home-coming queen and game films shot with overhead drones from a RadioShack closeout sale. Sure, RA brings its nodules, Sjogrens and scary, bent-fork wrists to un-nerve us. But we have the hall of famers (MTX, leflunomide, TNF inhibitors), triple threat (MTX-HCQ-SSZ) and rookie Phenoms (abatacept, rituximab, tocilizumab, tofacitinib) to battle whatever RA throws our way. We have technology (MRI, ultrasound, FDG-PET), statistics (T2T, RAPID3, GAS, MBDA) and the Yoda’s of RA therapeutics (Genovese, Weinblatt, Van Vollenhoven, Maini) to lead us to victory. With these players and that arsenal, it’s hard to imagine anything but victory. Yet, we need to recognize that we are not as good as we think we are, nor is RA as mild or well controlled as we might hope. Every Rheum has a handful of patients who haven’t read the textbooks or ACR abstracts attesting to the wunderbar success of biologics. These mutineers keep us awake at night, hold ineffective, or toxic, our best random choice of therapies and have us writing “Dear Dr. Weinblatt” emails for alternatives. We may have great people and great drugs on our side, but we lack a smart, specific approach to the one disease, RA, that is really 8-20 different diseases unified under a phenotypic or serologic umbrella.
- Psoriatic arthritis: WIN Rheums 28 – PsA 13. If we were playing in that Dermatology league, the score would have been much higher – given arrival of skin superstars ustekinumab and secukinumab. For us Rheums moving away or limiting the use of old worn-out MTX in PsA and making way for many of the newer agents has been a relief and easier win. Oh, and then there is that new rookie kicker, apremilast. Unclear if he’ll win us any games, but he can hope and we can watch. The NY state lottery slogan is "you've gotta be in it, to win it". Maybe he gets to play more this season.
- Ankylosing spondylitis/spondyloarthritis: WIN Rheum 17 – AS 3. AS is now SpA (radiographic or nonradiographic; axial or peripheral) – sort of like the Baltimore Colts becoming the Indianapolis Colts or the Baltimore Ravens. (It takes the same amount of time to explain both analogies). The good news is we should win these guys every time. The deficit is that not enough of them show up for us to run up the score. We need more deep-voice radio commercials, stiff-spined celebrities or cool genetic tests to re-revolutionize the diagnosis and treatment of AS/SpA – especially in Baltimore and Indianapolis.
- Osteoarthritis: WIN Rheum 35 – OA 27. I did the best I could with the limited players I could suit up. Analgesics, weak narcotics, NSAIDs, Cox-2 inhibitors, intraarticular steroids, weight loss and exercise might be enough to stay in the game and may be winners for some patients. But thank goodness for heavy metal and joint replacements. Arthroplasty surpasses our best plays and usually comes along at just the right time for our patients and fellow Rheums with the gimpy knee or hip.
- Inflammatory (erosive) osteoarthritis (EOA): LOSS EOA 33 – Rheums 3. If OA were a town, EOA would be like East OA – just a bader, faster, meaner and unstoppable version of OA. Yes, EOA is one of those opponents you’d rather not face. Let’s review my game plan – NSAIDs, acetaminophen, low dose prednisone, MTX, hydroxychloroquine, and TNF inhibitors and I only score 3 points! I’ve tried even more than that, failed badly with them all and am left to wonder if I can help these crooked DIPs and painful digits. Dad-gummit! (this was often exclaimed by my football coaches when the going gets rough). Secretaries, piano teachers, Pope Francis groupies – they’re my patients with EOA and I’m unable to make a difference. This continues to be a year-in, year-out, ass-whoopin’, frustrating LOSS of failed treatments. What else can I offer? Not much and with little optimism – difficult DIP or PIP injections, immobilization, IL-1 inhibition (one trial failed, another is in progress) or more off-label use of meds with a greater risk of side effects than efficacy (apremilast, colchicine, sulfasalazine, gold, pirfenidone, etc.). I may have to consult an herbalist on this one. We need help here!
- Dermato/Polymyositis: WIN Rheums 9 – DM/PM 3. This was a short week, played with only 3 real drugs – steroids, MTX and azathioprine. Sure there are others on the bench (like IVIG, cyclosporine, rituximab), who keep wanting to show me their press clippings. But antecdotes barely rivals wiki-medicine in guarantees and both fall short on the track record needed to either change or save lives. When will someone step up and make a difference here?
- Fibromyalgia: LOSS by Forfeit
- Pregnancy in RA: WIN Rheum 22 – Pregnancy 15. This is an out of league, exhibition. Rheums don’t often play here and when we do it’s with a uncertainties. It’s not because we doubt our rheumatologic prowess and athletic intellect. No, it’s more because these pregnant people are, well, different. Progressively monthly worsening managed by hand-holding? I’d rather play them before or after the pregnancy, when my hands aren’t quite so tied (by moms, OBGYNs, lawyers, package inserts). But, the game has changed. We know that inflammation is likely to be more hazardous than any category B, C or even D anti-rheumatic. We can use NSAIDs (between weeks 8-32), TNF inhibitors (pre-conception, during and post-partum), and steroids as needed. We can safely do imaging on pregnant women. We can safely co-manage the pregnant RA patient alongside the OB or maternal-fetal medicine specialist. My job is to manage the mothers’ arthritis; their job is to deliver a healthy baby. These tasks need not be in conflict.
We have done well in the past and should do better in the future. We have to win, too many depend on us!
*The above is a fictionalized account of the average Rheum (rheumatologists) battle against rheumatic disease – put in the context of sports and “teams”. No derogatory comments are intended for individual patients. The humor and truisms herein are directed at the disease states (teams) to portray the ease or dis-ease with which Rheums may approach and manage them.