“My calculation is that there are probably 75,000 new cases of RA every year in the U.S.,” Dr. Cush says. “If every rheumatologist made an exceptional effort to get those patients, it would mean an extra 20 to 30 patients a year, and they could absorb that with no problem. However, to capture these patients, the rheumatologist will have to see many more patients, as the yield for early inflammatory arthritis is usually less than 10%, even when promoting referral rules to primary-care physicians. You might have to see hundreds of patients with fibromyalgia to get one with early RA. So, why should somebody in practice revamp for what seems to be very little gain?”
Another challenge for rheumatologists is being referred a patient with symptom duration of one to two years. “In the last several years, I don’t remember seeing a patient with true early synovitis,” says Gary Firestein, MD, chief of rheumatology and immunology at the University of California, San Diego School of Medicine.
In the typical RA case, he says, a patient will stay at home and self-medicate for a few months. When there’s finally a doctor visit, the signs and symptoms of inflammatory synovitis may not be recognized; treatment will usually be conservative, perhaps with a non-steroidal anti-inflammatory drug. Another month or so may pass. When the patient returns to the doctor with continuing pain, tests are run and another couple of weeks go by before there’s a referral to the rheumatologist—who may have a wait of two or three months for an appointment.
How Early Is Early?
Although today’s ideal is early treatment, the actual definition of “early” varies. While some advocate treatment as early as three months, others prefer to wait.
“I think we need to be careful and not overtreat a patient with symptoms of joint pain,” says Larry Moreland, MD, professor of medicine at the University of Pittsburgh and formerly at the University of Alabama, Birmingham, who has participated in an EAC. “Often times patients have self-limiting problems and do not require treatment in the first few weeks,” he says, “and in about a third of the cases, the symptoms will resolve without therapy.” He adds that, “what we don’t want is to have a patient with RA go untreated for six to 12 months.”
However, “most PCPs have a hard time making the diagnosis of RA, even if it’s clear RA,” notes Dr. Moreland. “That’s because it often isn’t clear. Patients have vague symptoms. Making an RA diagnosis for me as a rheumatologist is pretty easy. But if you’re out there on the front line where you’re seeing all kinds of problems, it’s not easy.”
