Rheumatoid Arthritis - Unmet Needs and the Future Outlook in India - Q & A Session with an expert
(Focus - India)
Robotic-assisted surgeries are in huge demand. A robot is needed when the surgeon has very difficult access to the organs. However, being a cost-sensitive market, what will be the future of Robotic-assisted surgeries in India?
To learn more about it, we had a short discussion with Dr. Neeraj, a renowned Rheumatologist from India who mentioned interesting trends in the treatment and management of rheumatoid arthritis and the future outlook of robotic-assisted surgery in India. He also discussed the importance of public awareness for early detection of arthritis to reduce the cost burden to society.
Dr. Neeraj Jain is a professor at GRIPMER, Vice Chairman, and Senior Consultant in the Department of Rheumatology and Clinical Immunology at Sir Ganga Ram Hospital, New Delhi, India.
To be very clear, those who were on immunosuppressants and those who had very tight control of rheumatoid arthritis did very well, even if they got COVID. It was not like they got more COVID, but actually, they were more protected. Our patients who were on anti-TNF did very well, they had a very mild COVID, or they just had a positivity of COVID without any symptoms.
Let us begin with the epidemiology of rheumatoid arthritis. Recent estimates show that RA prevalence ranges from 0.24% to 1% in Europe and US, depending on various risk factors. Could you comment on the epidemiology of RA in India?
Dr. Neeraj - To be honest, we do not have very large studies from India, but based on a few studies that were done, the prevalence range is approx. 1% in India as well. But now, with more awareness about this disease and more referrals, I think the prevalence should be very high. Because now we see more RA patients in OPD than we used to see previously. However, we need long-term, dedicated studies to comment on rheumatoid arthritis epidemiology in India.
We understand that during the COVID-19 pandemic, the intake of immunosuppressants in RA patients was lowered to minimize the risk of getting severe COVID-19 infections. According to you, how has the COVID-19 pandemic impacted the prevalence of RA in India?
Dr. Neeraj - COVID-19 had some ups and downs with the treatment of rheumatoid arthritis. Many physicians had this understanding that the immunosuppressant would cause more harm to the patients, and they would get severe COVID-19 infections. So, there was media hype or general talk that those who are on methotrexate, leflunomide, and sulfasalazine, are more prone to catching COVID, which I think was verywrong. And this led to many people stopping their disease-modifying drugs. Also, hydroxychloroquine was used in COVID, so it went out of stock, which also impacted the treatment of rheumatoid arthritis.
To be very clear, those who were on immunosuppressants and those who had very tight control of rheumatoid arthritis did very well, even if they got COVID. It was not like they got more COVID, but actually, they were more protected. Our patients who were on anti-TNF did very well, they had a very mild COVID, or they just had a positivity of COVID without any symptoms. So, I think these drugs protected that they had good control of disease, so they were well protected from the consequences of COVID.
Basically, patients are being seen in peripheries with many painkillers and steroids, and then they're getting little suppression, and then again, the disease flaring up. So, we need more awareness about the disease.
What about vaccination doctor? Many patients worry that vaccinations may trigger autoimmune disorders. However, there are no large, controlled studies to prove whether vaccines provoke flares of underlying rheumatic conditions. What do you say, doctor?
Dr. Neeraj - I think they should all be vaccinated as per their schedule, like flu vaccines and pneumococcal vaccines. Even the COVID vaccine had no impact on the disease. It was some wrong belief that should be discouraged. So, vaccination had a very high protective role.
Diagnostic delays due to the lack of access to a specialist and costly therapies are still major obstacles for many RA patients even in the first world countries. In this context, where does India stand in addressing chronic diseases such as RA?
Dr. Neeraj - We have less of trained physicians dealing with RA and also the rheumatologist is proportionately less as compared to RA patient load. So, we lack treating doctors who can pick up rheumatoid arthritis early and treat them early.
Basically, patients are being seen in peripheries with many painkillers and steroids, and then they're getting little suppression, and then again, the disease flaring up. So, we need more awareness about the disease. Even in tier A cities, some media publicity needs to be there, like we, as a rheumatologist, give more awareness talks about picking up early rheumatoid arthritis or what is rheumatoid arthritis or what is arthritis even rather than rheumatoid. So, we must convey what is arthritis and what is just mechanical pain or is not arthritis. So, if we pick early, then we treat them early, and they do very well.
So, the dictum is to pick up early and treat as early as possible. We must have some planning on how to pick up early arthritis. Even in the western world, they have very early arthritis clinics. Since the literacy level is high, the patients quickly go to the doctor.
We need to have more awareness. If you want to place such gadgets in some tier B or tier C cities, people should be aware that there is something called arthritis, then only that person will be taken to the gadget. So, we need more awareness.
Recently, researchers in Denmark have developed a clinical robot called ARTHUR that can run automated ultrasound scans and detect arthritis within 15 minutes. According to you, what is the demand for ARTHUR in India?
Dr. Neeraj - If you ask me about the demand, it may be a boom for us. We only have a few trained physicians to see arthritis patients. So, if you talk about all these gadgets or machines, that will be great. If you place one robot in some city, and if that robot can scan hands or knees and then say if the patient has arthritis and is being referred to a rheumatologist or a physician, that will be great. This should be the way forward. However, India is a cost-constrained country, so the cost will be a big issue, or access to such gadgets will be a big issue. But yes, if it comes, it will be great.
Apart from cost, are there any other barriers?
Dr. Neeraj - We need to have more awareness. If you want to place such gadgets in some tier B or tier C cities, people should be aware that there is something called arthritis, then only that person will be taken to the gadget. So, we need more awareness.
Do you think people in India are aware of ARTHUR?
Dr. Neeraj - Very few people know about this.
What interesting trends do you foresee in the treatment and management of RA?
Dr. Neeraj - We have conventional drugs like methotrexate and leflunomide; they do very well. But we need some drugs like biologics for 15% to 20% of patients who don't go into remission. They do very well. Initially, the cost was a big issue with biologics, but now it has come down. And recently, for the last three to four years, we have had JAK inhibitors. So, oral biologics would be the way forward, and we need to have more such oral drugs because, in India, the public is more scared about injections. They run away if you tell them that their disease is not controlled, and they have to shift to anti-TNF injections. Suppose we tell them about any oral drug, they will easily take, like JAK inhibitors or BTK inhibitors. JAK inhibitors are doing remarkable things for RA. We should have more JAK inhibitors, and they are cost-effective as well.
Is there any reimbursement for expensive treatments of RA in India?
Dr. Neeraj - The insurance company covers once the patient is admitted. If you give them an oral drug and get them admitted, even if it is expensive, they will ask you why the patient has been admitted. So, they will see if the drug is given intravenously. But now, the trend is that patients are not opting for intravenous therapies, but they're opting for oral medications. I am not sure how the insurance company reimburses them. But all these oral drugs have become very cheap now. So, the therapy cost has been reduced to INR 2000 or INR 3000 per month. I don't know if we really need an insurance. Initially, it was an issue when prescribing injection drugs or when patients were admitted with high disease activity. But now it's quite manageable in the outpatient department as well. Even if we give them oral JAK inhibitors, they do well.
A robot is needed when the surgeon has very difficult access to the organs. The precision will be much better with robots; they do pinpoint corrective surgery, which is great because even a one-degree or two-degree angulation will be very helpful for rheumatoid patients. So, if a robot can help them, then it's good.
Despite advances in targeted biologic and pharmacologic interventions that have recently come to market, some people may still require surgery to ease joint pain and improve mobility. Do you see any advancement in the surgical treatment options for rheumatoid arthritis patients?
Dr. Neeraj - Definitely, for RA patients, basically for young females, the hand deformity is a big cosmetic issue, and their routine activities and work are hampered. So that's a big issue.
If patients come early and are getting good treatment, they will not go to a stage where there is a deformity. However, there is not much awareness, so patients come very late to us, especially those who live in remote areas. When they have deformities, it's disheartening to see them having deformities. If it really affects their daily life, then we need surgical intervention. According to my experience, almost 17 or 18 years from now, the most common would-be hand surgery which needs correction. So, we need more trained hand surgeons who deal with rheumatoid arthritis. They should have expertise in inflammatory diseases with deformities rather than just correcting a deformity. So, we need more surgeons trained in handling hand and feet or hand and knee surgeries.
What about robotic-assisted surgeries, doctor?
Dr. Neeraj - It is in huge demand. A robot is needed when the surgeon has very difficult access to the organs. The precision will be much better with robots; they do pinpoint corrective surgery, which is great because even a one-degree or two-degree angulation will be very helpful for rheumatoid patients. So, if a robot can help them, then it's good.
Now India is moving towards robotic assisted surgery, right?
Dr. Neeraj - No doubt about it. Even for all these urological, abdominal, and gynecological surgeries, if we can have some robots doing them, that will be great.
What do you think about the future outlook of robotic-assisted surgery in India?
Dr. Neeraj - Definitely, it will be great. Robots will have more precision. The only problem in India will be the cost because they add up to a high price to society. But yes, if we can have robots doing very fine work, then it is great. If we refer to hand surgery, we rarely get good surgeons dealing with hand surgeries. So, if robots can take care of it, that's fine with us.
Before we close, what do you suggest to patients and healthcare providers for timely diagnosis and treatment of RA?
Dr. Neeraj - First of all, we need to have good public awareness, maybe at a government level. If the government can take this initiative and raise awareness, in medical media, social media or on television, people will have awareness. For example, we were doing a lot of awareness about TB, leprosy, and so on. For polio, we did a good campaign. Likewise, they should have a campaign for early detection of arthritis so that we can pick it up early. So, if you pick early, we treat early, and you do very well, and that's not a cost burden to the society as well. Because once a young person develops arthritis and cannot go to work, that affects the families. So, we should have more awareness. As a health care worker, as a rheumatologist or trained physicians who are dealing with rheumatoid, we should take more public lectures with GPs, because GPs are the people who are in first contact with the public. So, if GPs can pick up early, then they refer to a specialist. We should give more public lectures, maybe like articles in the media.
Thank you very much for your valuable input, doctor!