Jeffrey Sparks, MD, MMSc, discusses what rheumatologists need to know about treating challenging cases of rheumatoid arthritis as well as the risks and benefits of more aggressive treatment strategies.
In an interview with HCPLive Rheumatology, Jeffrey Sparks, MD, MMSc, discusses his Congress of Clinical Rheumatology West presentation, “Difficult to Treat Rheumatoid Arthritis.” He explains what rheumatologists need to know about treating challenging cases of rheumatoid arthritis (RA) as well as the risks and benefits of more aggressive treatment strategies.
“Even though there have been many advances in therapies, there are many patients who are refractory to different options,” Sparks said. “In this talk, we dissect reasons for why patients might be difficult to treat. It's a very heterogeneous group. Some people may not actually have RA; some may have pain due to other reasons or comorbidities, or side effects from medications that make things difficult to treat.”
He also delved into the research definition of difficult-to-treat rheumatoid arthritis, which focuses more on refractory, active disease. However, there are still some patients who might not fit neatly into that definition, possibly due to symptoms not related to inflammation.
Other patients become dependent on glucocorticoids, due to active disease or other effects that steroids can have, making it challenging to wean off.
“This is something rheumatologists face daily, where patients may not fit into established categories, making it a topic of emerging research interest,” he explained.
The risks and benefits of glucocorticoid usage has been an ongoing debate in rheumatology. Some patients may need bridging therapy with glucocorticoids, but for the most part, long-term glucocorticoid use is viewed negatively due to metabolic side effects such as weight gain and osteoporosis.
However, it is still commonly used, and many patients end up relying on glucocorticoids despite available options. This remains a relevant area in rheumatology because of the drug's rapid action and its use in treating patients with ambiguous presentations or acute episodes that require prompt intervention.
Lifestyle factors, including diet and exercise, also play a role in rheumatoid arthritis. While they complement treatment, they are unlikely to be enough to manage the immune changes and inflammation associated with RA.
“Excess weight and diet can contribute to inflammation,” Sparks stated. “Maintaining fitness and muscle mass through physical activity is important. The holistic benefits of physical activity on mental and physical health are significant. So, lifestyle factors are important across all phases of rheumatoid arthritis treatment.”
However, Sparks explained these measures are unlikely to replace medications entirely. The American College of Rheumatology has provided recent guidelines on non-pharmacologic measures, but the data is of relatively low quality due to the challenges of conducting high-quality, randomized, blinded trials for these interventions, which would require large sample sizes and blinding, which may not be practical.
This transcript has been edited for clarity.
Dr. Sparks has consulted for Bristol Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer.