Rheumatologists want to intervene as early as possible when caring for patients with rheumatoid arthritis (RA) to minimize permanent damage and maximize patient quality of life. Our experts discuss effective early intervention strategies, the challenges of managing primary care provider referrals, the efficient use of drugs such as methotrexate, and the need to address systemic barriers to care.

We want to intervene as early as we can in RA, knowing that this is a progressive disease that causes irreversible damage once it occurs and has systemic implications. I hear from colleagues that there is sometimes uncertainty about when the diagnosis is clear-cut and that they hesitate to use a medication with potential side effects until they are absolutely certain of the diagnosis. That is the challenge: finding a place where you are comfortable enough that the diagnosis is accurate and can initiate therapy without feeling that you may be jumping in too soon with treatment that may have potential adverse consequences.

There is a significant rheumatologist backlog, and part of the challenge is that a lot of patients who are referred to a rheumatologist do not need to be referred, which does not give us availability for the patients we do need to see. If we cannot get referred patients in to see us in a timely manner, providers will often reach out and ask what they can do for them in the short run. We usually advise providers to avoid steroids and to make sure that they order the necessary testing, and we will try to squeeze the patients in. Some patients may have already been on steroids by the time they see us, and being informed of whether they responded can be somewhat useful information. For patients with positive antinuclear antibody (ANA) tests, we have put together a rapid telehealth consult system in which any positive ANA gets flagged. We see those patients in 30-minute telehealth sessions because we have found that many of the ANA tests that are ordered are not clinically relevant.

Other patients with RA who are referred to a rheumatologist have already failed multiple therapies, but they may have cycled through these therapies very quickly. Should we still start with methotrexate? Yes, but you can do it in a thoughtful and expeditious fashion without waiting 6 or 9 months to know whether methotrexate is going to be sufficient. You usually know if there will be benefit within 3 or 4 months of starting therapy if you appropriately increase the dose.

There is a short period early in this disease when erosions will ramp up rather quickly, and this is the time when you want to press on with therapy—you do not want to wait. Studies show that if a patient has not responded sufficiently to a particular therapy by 3 months, they are likely in a group that will not respond if you wait longer, and that is when you move on to a different treatment or to a treatment escalation. This data value was a result of the many strategy studies in the literature. You want to get these patients with RA on an effective medication, at the very least within the first year.

However, the danger is that, even with biologics, some providers in the community may rotate the patient very quickly through a series of individual therapies, without giving each therapy enough time to produce a beneficial effect. And when the patient ends up seeing me, I discover that they have been underdosed on multiple medications, and I sometimes have to start all over again.

When talking about early treatment, it is important to note that there is work being done to identify and treat patients who are diagnosed with pre-RA with the goal of actually preventing or delaying the onset of actual diagnosed RA. These efforts to prevent disease are often based on a patient’s biomarkers, genetics, and family history. Where is this taking us? I have some concerns about the practicing rheumatologist moving too far in this direction without more precise data on risks and benefits.

The challenge is not just for the rheumatologist. The challenge is getting patients to the rheumatologist in a timely manner, which is a decade-old issue that is only increasing as primary care providers are often relying more on laboratory tests rather than on physical examinations. This can result in patients being either overreferred or underreferred, as RA may not always be very high on the differential list when someone shows up to their primary care provider with joint pain. The other issue is a problem on our end, as rheumatologists. The workforce crisis is a major concern across the United States, and it is not unusual for patients to wait 3 to 6 months to see a rheumatologist, which is totally unacceptable given the importance of earlier intervention in RA.

We need to provide instruments to the primary care team that help them know when to consider RA. I think that the rheumatology community uniformly appreciates the need to start effective therapies as soon as you are comfortable with the RA diagnosis.

We are currently not seeing the issue of a delay in the initiation of a DMARD compared with what we were seeing a decade ago. However, I do feel that we are still underdosing methotrexate, and many providers go too quickly to a biologic. Our challenge is to educate colleagues about how to properly initiate methotrexate, while also not lingering on methotrexate when patients are unresponsive and should be on an additional therapy.

In my opinion, the biggest problem with laboratory tests in RA is not the cyclic citrullinated peptide antibody tests. I welcome those referrals. But we are absolutely drowning in positive ANA tests, where patients are being sent to us for fatigue and positive ANA tests. On the other hand, the primary care provider sometimes will say that a patient does not have RA because their erythrocyte sedimentation rate and C-reactive protein levels are normal. And yet, we know that more than 30% of patients with active RA have normal acute phase reactants.