About 20% of people with RA fit the description of having “difficult to treat” or refractory disease, according to experts. As more is known about this subgroup of patients, potentially through evolving understandings of biology, clinicians can better treat their disease and pain. 

Dr. Navarro-Millan covered definitions of difficult-to-treat-RA. ACR does not currently have a definition, but EULAR describes this as a failure of at least two or more biologics or targeted synthetic disease-modifying antirheumatic drugs (DMARDs). In addition, the management of signs and symptoms may be perceived as problematic. At least one of the following signs must be present: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and the management of signs and/or symptoms are perceived as problematic by the rheumatologist and/or the patient.

The hope, said Dr. Navarro-Millan, is to homogenize the definition, teasing out which clinical manifestations are due to inflammation that would require a decision to increase or modulate the immunosuppression.

Dr. Bridges discussed current research agenda for difficult-to-treat-RA. In patient-related factor research, there is a need to look at non-pharmacologic approaches, such as smoking cessation, diet, and multidisciplinary care. Some physician-related causes may be tied to failures of the current healthcare system, such as requiring patients to fail one drug before trying another. And in the area of disease-related factors, the number of publications related to RA (along with lupus and cancer) has increased greatly – meaning our understanding of its pathophysiology is slowly informing new treatments.

For instance, the use of artificial intelligence may soon help clinicians predict RA disease activity at future clinic visits based on information in the electronic health record, shared Dr. Bridges. He cited a 2019 study on the assessment of a deep learning model based on data that predict RA flares. While the model worked well in a university hospital, with more complete records, and better-supported patients, the same model applied to a safety-net hospital, where patients may not have all the resources they need, did not work as well. The findings indicated, he said that, “We really have to focus on the social determinants of health – all the nonbiological aspects of treatment that should be considered when we talk about RA.”

Read the full article at www.practicalpainmanagement.com/.

HSS rheumatologist Iris Navarro-Millan, MD, and colleagues conducted a retrospective, longitudinal analysis of data from 2006 through 2016. The analysis consisted of six cohorts, three of which used data from SSDI beneficiaries and three from patients enrolled in Marketscan, a health care research database. Patients in all cohorts were aged 40 to 65 years.

A total of 380,336 patients with RA, with an average age of 53 years, were included in the analysis. Overall, there was a higher rate of comorbidities among patients on SSDI, compared with those on commercial insurance, according to the researchers. In the second cohort, including patients receiving a disease-modifying antirheumatic drug (DMARD) for therapy, patients receiving SSDI demonstrated a higher risk for CVD (HR = 1.23; 95% CI, 1.14-1.33), compared with those on commercial insurance. There was no statistically significant difference in CVD risk in the third cohort.

Read the full article at Healio.com/news/rheumatology.

Dr. Navarro-Millan emphasized the need to take care of your mental health and heart health, noting the added risk patients with rheumatoid arthritis (RA) have for atherosclerotic cardiovascular disease. “Your mental well-being is as important as your physical. Also, if you have rheumatoid arthritis, taking care of your heart is part of taking care of your RA, too,” said Dr. Navarro-Millan.

Read the full article at Creakyjoints.org.

Dr. Navarro-Millan explained one of the challenges, “It’s not genetic makeup that makes you by default predisposed or not predisposed to an issue, but it is also to the social environment. That social environment has to look beyond the phenotypes of race and ethnicity. The way that you get to understand that better is by following a systematic, strategic, data collection of social determinants of health.”

She continued, “collecting systematic data on social determinants of health will be important for us to know where to identify actionable gaps in health disparities.”

In order to facilitate change, Dr. Navarro-Millan underscored the importance of understanding how clinical care challenges are influenced by the ways that policies in the health care system have been implemented.

Listen to the full episode at Rheumatologyadvisor.com.

Dr. Navarro-Millan called for more diversity in the work force, improving health literacy, and reducing barriers to care.

Read the full article at Everydayhealth.com.

Dr. Navarro-Millan said, “If there is something there that is tickling here or there, [the immune system] starts getting angry and starts attacking it quickly. It starts identifying things [like] your joints as foreign intruders.”

She continued, “Men’s immune systems tend to [let] them pass. ‘Eh, it’s okay. You can hang out there.’ But women’s immune systems [are] going to just go straight and attack it, even if it’s your own organ.”

Watch the full video interview at Healthination.com.

The four stages of rheumatoid arthritis are known as synovitis, pannus, fibrous ankylosis, and bony ankylosis.

“As a soon as you have joint swelling and severe pain that impairs your ability to move around, then you have to start thinking the right doctor for you is a rheumatologist,” said Dr. Navarro-Millan.

She added, “Early treatment is key in order to prevent the progression of RA that could probably limit your everyday ability to live life to the fullest, so you can stay as healthy as you can.”

Watch the full video interview at Healthination.com.

Dr. Navarro-Millan explained, “Simple tasks are very difficult for people living with RA and it's because of the pain. Things that we take for granted are not that easy for people with rheumatoid arthritis.”

Dr. Navarro-Millan recommended kitchen tools such as electronic can openers, mandolines or jar opener grips to minimize the strength put on joints to avoid discomfort and ability to live independently.

Watch the full video interview at Healthination.com.

“The right treatment for rheumatoid arthritis can help you live with more independence and dignity, which is my goal as a rheumatologist,” explained Dr. Navarro-Millan.

Watch the full video interview at Healthination.com.

According to Dr. Navarro-Millan, most of her patients with rheumatic diseases have been eager to be vaccinated, however she sees more vaccine hesitancy among new patients with lingering COVID-19 symptoms that mimic post-infectious rheumatic disease. “We are finding that getting a COVID vaccine improves long-COVID symptoms,” said Dr. Navarro-Millan.

When Dr. Navarro-Millan talks with vaccine-hesitant patients, she explains the vaccine provides peace of mind. Patients can safely visit their family and friends again, she says, framing the conversation in personal terms rather than stressing efficacy data. “I tell my patients, ‘That is what I want for you—that human connection that we have all been missing,’” she cited. “Patients just want to have a connection with a real person when they talk to their doctor. They don’t want to talk about statistics.”

When Dr. Navarro-Millan recently hosted a vaccine education webinar in both English and Spanish, patients asked if they would have a lesser response to the COVID-19 vaccine because of their rheumatic disease therapies. She explained that for patients on B cell therapies, they may have a lesser response and could require a booster vaccine dose in the future to achieve optimal protection against COVID-19.

Read the full article at the-rheumatologist.org.

“We know what happens to patients with the Flu vaccine, the Shingles vaccine,” said Dr. Navarro-Millan. “They [patients] tend to feel not so well, fatigue, and in some instances people do develop a flare,” she continued. However, the ACR recommends patients with rheumatic conditions should get the COVID-19 vaccine, stating the benefit outweighs the potential risk of a flare or the disease worsening.

“So the bottom line is the risk of the flare, even if it’s a bad one that makes you feel bad, it’s still not as bad as getting a serious COVID-19 infection that can put you in the hospital,” added Dr. Navarro-Millan.

Watch the segment at NBCmiami.com.

Additional coverage: Telemundo51.com on February, 23 2021.

“A large number of RA patients don’t even get a cholesterol test,” noted Dr. Navarro-Millan. While cholesterol is just one piece of the heart-health puzzle, patients who are missing this most basic metric are not likely to be having more in-depth discussions about heart disease with their health care providers, she added.

Dr. Navarro-Millan continued, “Many RA patients are not screened for diabetes, but they don’t know it.” She explained that anyone with diabetes automatically should be taking a statin, a medication that reduces the risk of serious cardiovascular events by lowering cholesterol, reducing inflammation in the arteries, and stabilizing plaque so it’s less likely to break off and block blood flow.

Read the full article at Creakyjoints.org.

Panelists discussed common myths about the flu vaccine, and offered information on the differences between COVID-19 and the flu, including how to tell symptoms apart, what to do if you suspect being infected, and how to get tested for both illnesses.

View the full webinar at CreakyJoints.org.

“Women’s immune systems seem to be more robust than men’s,” explained Dr. Navarro-Millan. However, this disease-fighting superpower could put immune systems into overdrive, leading them to misguidedly attack joints. As a result, women are also much more likely to have autoimmune-related joint conditions such as rheumatoid arthritis and lupus.

Read the full article at Goodhousekeeping.com.

Read the full article at NYTimes.com. This article also appeared in print. 

Read the full article at NYtimes.com.

Risk factors for cardiovascular disease, such as hyperlidipaemia are not identified or managed in RA patients as it often falls through the gap between rheumatology and primary care provision. The researchers conducted a series of structured focus groups with rheumatologists and primary care doctors nationwide to understand why this is happening. While primary care physicians believe that reducing cardiovascular risk of patients is part of their role, they do not know enough a bout how lipid lowering treatment could influence symptoms of RA or how inflammation from RA disease and treatment may influence lipid profiles to manage risk confidently. Both groups of doctors also said that challenges in coordinating care between them also acted as a barrier to screening for and managing hyperlipidaemia.

The researchers wrote, “Our results and that of others support the need for patients with rheumatoid arthritis to have a primary care physician, which might not only increase the likelihood of cardiovascular disease screening itself but also enable the implementation of interventions that can increase cardiovascular disease risk screening and reduction.”

Read the full article at Rheumatologynetwork.com.

Read the full article at Beckersspine.com.

Additional coverage: ryortho.com. 

ConsumerReports.org spoke to Iris Navarro-Millan, MD, rheumatologist at HSS, who emphasized the importance of getting your condition under control. Studies have shown that RA patients who are on a treatment have a 15 to 85 percent reduced risk of getting or dying from cardiovascular disease. Similarly, when patients with psoriasis are being treated with biologics, it can reduce plaque buildup that clogs arteries.

Read the full article at ConsumerReports.org. This article also appeared in the July 2019 print edition.