As a rheumatology nurse practitioner with 16 years of experience, I have seen a lot of patients with rapidly progressing disease. Unquestionably, after nearly 2 decades of experience with biologic therapies, the use of early, aggressive therapy is best for most of our patients with RA. Recent recommendations from the American College of Rheumatology (ACR) support rapid escalation of treatment in patients who do not respond to initial and subsequent therapeutic regimens.1
However, we should recognize that there are always outliers to early and aggressive treatment plans. One such patient of mine is Deb, a 59-year-old woman who presented to her primary care physician in 2011 with pain in multiple joints, especially in her hands, which was affecting her activities of daily living. Lab tests showed that Deb had a positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP), which prompted a referral to a local rheumatologist. Based upon an erythrocyte sedimentation rate (ESR) of 50 mm/hr and a C-reactive protein (CRP) of 2.6 mg/L, she was started on methotrexate (MTX), which I am sure most of us would concur was the most logical starting point.
Two months after starting MTX, Deb did not feel any better and went back to her rheumatologist to ask what else could be done. She explained that her joint pain was as bad as ever. Since current Treat to Target guidelines recommends switching therapy frequently (“at least every 3 months”) in patients who do not reach their treatment target,2 Deb’s rheumatologist decided that the most appropriate step would be to initiate a conversation about adding adalimumab to her MTX regimen.
This, however, is where the story diverges from the expected path. Deb was not comfortable with the discussion around the addition of a biologic. She did not feel that her rheumatologist listened to her or answered her questions appropriately. As a college-educated woman, she wanted answers that made sense, and she didn’t feel as if she had gotten them. Consequently, Deb went to another rheumatologist for a second opinion.
At this visit, X-rays were taken, and no structural damage was seen. While her ESR and CRP levels were still elevated, Deb’s new provider listened when she told her that her morning stiffness lasted for only 1 hour, about 30 minutes less than a few months ago before she started MTX. Consequently, instead of escalating her to a biologic, she was taken off the MTX and started on a new NSAID.
Two months later, on her initial return visit, I met Deb. She was doing about the same as before—no worse but no better. We talked about her immune system and specifically focused on ways that lifestyle changes could improve her quality of life. Deb was clearly a scared patient—scared by being diagnosed with a chronic, lifelong disease, and scared that her initial treatment forays had not resulted in noticeable improvements in her symptoms. She wanted to take better control of her disease, so she agreed to start exercising more and initiated a weight loss program.
After a few cycles of “yo-yo dieting,” she came back to me for a re-check of her RA. My initial step was to order a multibiomarker disease activity score (MBDA) test to assess her current disease activity. Her score came back as a 30, showing low-to-moderate disease activity. Upon questioning, Deb reported that her morning stiffness still generally lasted about an hour or so, but that her joint pain had improved with regular exercise and use of the NSAID. At this point, I felt reassured that we were on the right path since her MBDA score was in the low-to-moderate range, and we continued with conservative therapy.
On her next return visit 3 months later, Deb looked discouraged, and I immediately knew that something was wrong. Her weight issues remained a problem, as evidenced by her high leptin levels (which can be fueled in part by being overweight).3 Deb explained to me that she had tried and failed 3 different weight loss programs in the past few months.
Sensing her frustration, we decided to try a weight‑loss medication—lorcaserin HCl—to see if that might help. Six months later, Deb had lost 20 pounds and had significantly reduced pain and increased energy. She requested that her NSAID dosage be reduced, and she seemed highly motivated to lose 15 more pounds to get her closer to her goal weight.
I spoke to Deb about an anti-inflammatory diet called the Whole30 Programs that encourages people to eliminate foods thought to be related to inflammation such as sugar, grains, dairy, and legumes for 30 days.4 While remaining on lorcaserin, Deb decided to give this program a shot. After 30 days, she had dropped 10 more pounds. As her weight went down, her joint pain improved. Being curious, I retested her RF and anti-CCP; both tests were now negative. Her most recent MBDA score is <20.
Quick admission: In my 16 years of experience, I have only seen 3 cases of RA that seemed to go away and stayed in remission on NSAIDs alone. Deb is not, therefore, a typical patient. I do believe, however, that in our patients with RA whose immune system is turned on, lifestyle changes can have a profound effect on reducing inflammation. Deb is one of those patients with a positive attitude, and she was willing to try anything to get her disease in remission with the fewest medications possible.
While we should always heed the recommendations of expert consensus groups such as those coordinated by the ACR regarding the treatment of disease, we should also remember that not every patient will respond to treatment regimens the way we expect. There is often only a narrow window of opportunity to listen to a new patient and help them respond to the changes of their immune system. Treatment needs to be tailored to the individual and not to the numbers on a page. By listening to and hearing our patients, we may sometimes be led in atypical directions that nonetheless help our patients solve their most significant problems.
AUTHOR PROFILE: Iris Zink, MSN, NP, RN-BC is a nurse practitioner at Lansing Rheumatology in Lansing, Michigan, and President of the Rheumatology Nurses Society.
Reference
1. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016;68(1):1-26.
2. Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016;75(1):3-15.
3. Allison MB, Myers MG Jr. 20 years of leptin: connecting leptin signaling to biological function. J Endocrinol. 2014;223(1):T25-35.
4. Whole30. Available at http://whole30.com/. Accessed February 14, 2017.