By Dr Irwin Lim, Rheumatologist
My rheumatology colleague, Andrew Jordan just presented a rheumatoid arthritis case at our GP meeting.
A 60-something year-old lady presenting with swelling and pain involving the small joints of her hands. Early morning stiffness and some carpal tunnel symptoms. A pretty classic story.
The diagnosis was made even easier by the presence of an elevated rheumatoid factor in her blood tests, and raised inflammatory markers.
The GP was astute and referred her early. She presented to a rheumatologist within 2 months of the onset of her symptoms.
Methotrexate was commenced with a small dose of Prednisone to help calm her symptoms. Within a few weeks, Prednisone had been weaned and ceased. She continued only on Methotrexate and was doing well.
One and a half years since her presentation, she remains in remission, both from her point of view and from the point of view of DAS-28 remission. She is symptom-free with absence of synovitis, the swelling rheumatologists look for when they examine joints.
All this on Methotrexate alone. 2 small tablets (10mg each) once a week only.
Easy.
This is a near-perfect example of the window-of-opportunity.
Rob Russo then made a telling comment. A decade or two ago, it would be strange to talk about an “easy” case of rheumatoid.
And of course, many cases don’t pan out like this. Some patients have terribly aggressive disease. Sometimes, there are all sorts of logistical issues preventing early rheumatology review and early treatment.
There’s a lot of debate currently about the very expensive treatments we use for rheumatoid (read about triple therapy vs biologics).
There are massive cost savings to be had if we can treat patients early.
Within this window-of-opportunity, Methotrexate, a very cheap medication, works well for those who tolerate it.