Rheumatoid Arthritis – Continuous monitoring and moderate physical activity are the keys
2nd February is Rheumatoid Arthritis Awareness Day and observing this occasion, we bring to you an interview with Dr. Shantene Selvadurai, a renowned Internal Medicine Physician from Malaysia, wherein she discussed about the role of telemedicine in managing rheumatoid arthritis.
Dr. Shantene Selvadurai is currently serving as a Rheumatology Fellow and General Physician (Internal Medicine) in Tuanku Ja’afar Hospital, Seremban.
Mainly for rheumatoid arthritis patients, we also have phone apps to key in their joint counts and tell us how they feel and the status of their joints (swollen or not). So, by keying them in via an app that we can access, we could remotely monitor our patient's conditions.
Thank you, doctor, for participating in this interview.
We understand that the triggers for the onset of rheumatoid arthritis are unknown. But are there any genetic and environmental factors that are appeared to be involved?
Dr. Shantene: Yes, it is thought to be multifactorial with genetics factors (HLA genes), environmental factors ( smoking, chemical exposures), and autoantibodies like RF and ACPAs complex interplay. The gut microbiome is one of the leading hypotheses which has been going on for over a decade. Besides that, any form of bacterial, viral, or parasitic infection can also trigger rheumatoid arthritis development.
It is impossible to ascertain the exact cause for RA, however. Every patient is different in many ways. e.g., ethnicity, gender, family history, occupation, co-morbidities, etc.
There is a concern that patients with rheumatoid arthritis are at higher risk of developing severe COVID-19, which leads to hospitalization or even death when compared to those without rheumatoid arthritis. In this context, how do you think RA patients are being treated and managed in Malaysia?
Dr. Shantene: Management is mainly based on the ACR recommendations for the Covid-19 vaccine for rheumatic and musculoskeletal disease patients.
Generally, patients with rheumatoid arthritis are immunocompromised due to the disease itself and immunosuppressive medications, which makes them prone to have COVID. Theoretically speaking, RA patients would have more severe forms of COVID 19, if infected.
In Malaysia, we started to vaccinate our patients as early as possible, up to a 3rd dose. The vaccines used were Pfizer, Sinovac or Astra Zeneca. Hence, the majority of our patients did not suffer from severe COVID-19. During their infection period, their immunosuppressive medications were put on hold, to enable them to fight the infection and recover. If joints flared, steroids at minimal doses were prescribed.
In summary, the hospitalization and death rates of RA patients were similar to that of the normal population, based on our observational studies.
During the pandemic, do you see a role for telemedicine in managing rheumatoid arthritis and other such chronic diseases?
Dr. Shantene: Yes, for most of our rheumatic and musculoskeletal disease patients, we had teleconsultations, we used to make phone calls. Mainly for rheumatoid arthritis patients, we have a phone app called myRA touch where patients key in their joint counts(swollen or tender) and tell us how they feel. So, through the app, we could remotely monitor our patient's conditions. This app auto-calculates the DAS activity (DAS 28 score) according to ESR or CRP that the patient is giving. So, teleconsultation was our primary method during the early COVID pandemic times.
However, nothing can beat seeing the patient at the end of the day, it provides a wholesome treatment plan for both patient and doctor.
Besides patient empowerment, we do have public education programs, whereby we invite our patients as speakers to these programs to share their stories. We have patients who have success stories of walking from a wheelchair and moving on with their daily activities. So, this is how we educate our patients.
So, before moving to the next question, we would like to congratulate you on your poster presentation on awareness of the musculoskeletal disorder and their health impact among civil servants in Malaysia and the prevalence of depression and anxiety in patients with rheumatoid and psoriatic arthritis and its contributory factors (EULAR 2020)
Dr. Shantene: Thank you.
What do you suggest should be done to promote awareness about rheumatoid arthritis?
Dr. Shantene: We practice many approaches here in Seremban, Negeri Sembilan to create awareness as we have a pro-active and dedicated head of Rheumatology, Dato Dr. Gun Suk Chyn.
First and foremost, we start with patient empowerment programs, which means we educate our patients to understand their disease. We ask them to register and encourage them to use the myRA app. We have been practicing that even before the COVID pandemic era. So, this empowers the patient to understand the disease severity and their joint activity periodically. We also keep track of each review.
Besides patient empowerment, we do have public education programs, whereby we invite our patients as speakers to these programs to share their stories. We have patients who have had success stories of walking from a wheelchair etc. and being completely independent now with proper treatment. So, this is how we educate and boost morale among our patients.
Thirdly, it is to educate our doctors as well. We reach out to doctors at all levels. It can be from district doctor primary GP to physicians on the tips to early identification of red-flag symptoms. Hence, we advocate for them to reach out to the rheumatologist as early as possible. We have groups over WhatsApp, Facebook, and Instagram, from where the patients are picked up, and they are referred to us at the earliest.
Other than that, we do have events like fun runs and walks. Previously, we used to do it physically, but now we have virtual walks. We encourage patients to take part, especially arthritis patients, to do walks within certain limits, like 10,000 steps or 20,000 steps to cover within a specified time. As an encouragement, they sign up for fancy T-shirts and goodies too. These have been practiced for the past few years now.
So, these are some of the methods that we practice besides going into remote districts and providing talks.
Tell us about any advancements in diagnosis and treatment for rheumatoid arthritis?
Dr. Shantene: Firstly, the use of ultrasound, now that we have access to it much earlier, has made the diagnosis of RA clearer, as we are able to pick up erosions and evidence of synovitis even before a patient develops clinical X-ray erosions. So, this is a good thing. The earlier DMARDs are started, the better the prognosis.
Secondly, regarding the management, we now have many choices of oral DMARDs, SC and IV biologics, and oral targeted synthetic DMARDs, such as tofacitinib, upadacitinib, baricitinib, etc. to choose from.
The only limitation to prescribing biologics is the cost itself. Hence, we try our best to look for funding for patients.
The good news is with the competition between generic and biosimilar biologics drugs. The prices have now been slightly reduced. This enables us to help more patients with active diseases.
Before we conclude this discussion, what are your closing remarks for rheumatoid arthritis patients?
Dr. Shantene: Rheumatoid arthritis is still a common condition. The prevalence is about 1% worldwide. It is ultimately important to be able to pick up signs and symptoms early and refer them to a rheumatologist through a proper channel as early as possible. Also, the public needs to be aware that rheumatoid arthritis can be treated well especially with early diagnosis, hence preventing joint deformity/damage.
Thank you very much for your time and viewpoints on rheumatoid arthritis.