The Window of Opportunity in Arthritis Treatment: How USBJI Can Keep it Open
As a field, rheumatology is undergoing a revolution in thinking made possible by advances in the scientific understanding of disease as well as the availability of new therapies. At a recent meeting, I attended a lecture on an emerging concept in the treatment of rheumatoid arthritis (RA) called the window of opportunity. The window of opportunity represents a period of time during the course of RA in which treatment may be uniquely effective in influencing the long-term course of disease. This effect may be to reduce the total time and intensity of treatment to keep disease under control or even to induce a state of remission or low disease activity. If substantiated further by rigorous clinical trials, the concept of window of opportunity would represent a “game changer” in the field of rheumatology.
The change in the treatment landscape of RA has been remarkable. RA is the most common form of inflammatory arthritis that, if not treated adequately, can lead to severe pain, deformity and disability. In the past, this condition limited both quality of life and longevity, with the diagnosis of RA often carrying a grim prognosis. The prospects for patients are now dramatically better. Current treatment involves the initiation of therapy early in the course of disease (“early aggressive therapy”) prescribed to “treat to target” or “T2T.” The target is remission or low disease activity which can be assessed by a joint count (number of tender and swollen joints), an objective measure of inflammation (C-reactive protein or sedimentation rate), and a patient global assessment (“on a scale of 0 to 10, how is your arthritis?”).
While T2T therapy can produce remissions in an increasing number of patients, many patients do not respond adequately to current treatment and, when evaluated initially, already show evidence of joint damage as seen by X-ray examination of joints. Furthermore, many patients may not get rheumatologic care until months or years following the onset of symptoms. This delay occurs because patients are not aware that their joint pain and other symptoms such as fever or fatigue result from an inflammatory arthritis. Unfortunately, providers may also not recognize the signs and symptoms of RA, especially early in disease course where findings of joint tenderness and swelling may be subtle. As a result, time passes, arthralgia turns into arthritis, and a window of opportunity may close.
The existence of the window of opportunity has not yet been fully verified but the concept makes sense and data do suggest that the earlier the treatment is begun, the better the long-term outcome. It is therefore important to initiate therapy as soon as possible since it may be able to hit the target more accurately and more frequently. Using another metaphor, as rheumatologists, we like to put out the fire when it is just smoking and not yet blazing. As this point, the issue becomes one of public health and improving the conditions in the health care system for patients and providers to implement best practices in a patient centric way.
When a health care issue moves into the arena of public health, organizations like the United States Bone and Joint Initiative (USBJI) have a critical role especially when partnering with constituent organizations like the American College of Rheumatology and the Arthritis Foundation. Improvements in public health require awareness, advocacy and education. The USBJI, through BMUS, has provided critical information on the frequency and impact-both personal and societal-of conditions like RA to raise awareness of the problem and underpin advocacy for resources to assure that all patients with an inflammatory arthritis can receive appropriate care. Furthermore, USBJI advances research and training, with the Young Investigator Initiative (YII) boosting the academic careers of those who, for example, would like to develop tools to detect RA earlier or design treatment strategies that can be applied during any window of opportunity to slow if not halt disease progression.
Through its Experts in Arthritis program (EIA), the USBJI can educate the public about the nature of arthritis and steps that patients can personally take to achieve better outcomes. I am very pleased that the American College of Rheumatology has recently agreed to cooperate with the USBJI on this valuable program, identifying EIA as an activity of micro-volunteerism for ACR members. Having myself given public education programs, I am convinced of the value of the dialogue between an expert and patient about the nature of arthritis. Unfortunately, the public still has many misconceptions about the nature of arthritis. These misconceptions urgently need correction. The major one is that arthritis is an inevitable consequence of aging. Simply, RA is not a problem of aging and patients need to seek specialty care when they become symptomatic so that therapy can be begun promptly.
Finally, through its MS4 program, under the leadership of Dr. Bruce Browner, the USBJI is designing a curriculum that will increase knowledge of musculoskeletal disease for medical students. Despite the frequency of musculoskeletal conditions in the population (a point BMUS clearly documents), most medical schools devote very limited time to education about their pathophysiology. Time spent on the anatomy of muscle and bones is not the same as time spent on the etiology and pathogenesis of RA or osteoporosis and their treatment. It is essential that medical school curricula devote adequate time for conditions like RA which affects 1% of the population and, according to BMUS, entails huge costs. The MS4 program is an exciting initiative since it is interdisciplinary and will engage many constituent organizations of the USBJI.
The development of biological agents such as TNF blockers and the new targeted synthetic disease modifying anti-rheumatic drugs like the JAK inhibitors to treat RA has been extraordinary and provides the tools to enhance patient outcomes and quality of life even further than now possible. I am very glad that the USBJI is taking a lead in this area and is working with its constituent organizations to make sure that everyone knows that there may be a window of opportunity and that patients have access to subspecialty care before the window closes.