When rheumatologist Erdal Diri started working at Trinity Health Center in Minot, N.D., a decade ago, he saw many rheumatoid arthritis patients referred to him by surgeons frustrated by the levels of joint inflammation they saw.

“Most of these patients were ending up with orthopaedic surgeons and during surgery, they opened up their joints and they were so inflamed that they closed them up and sent the patients to us” to get the inflammation under control before joints could be operated on, recalls Dr. Diri. Better inflammation-fighting drugs and a new approach to treating RA more aggressively has changed that, he says.  From an average of 30 to 40 RA patients being sent for surgery a year at this rural hospital, Dr. Diri now sends only 4 to 5.

“We get control of inflammation at an earlier stage, and we don’t see the joint deformity that we used to see, so the numbers of surgeries are going down. We are living in the anti-TNF era, and we’re seeing the results of that now,” he says.

Biologic drugs that suppress inflammatory agents like tumor necrosis factor (TNF) and others are indeed making a positive impact for people with RA. Surgery to repair joints deformed by RA is down sharply nationwide over the last 20 years, according to recent research.

The most recent study, conducted by rheumatologists at the Mayo Clinic in Rochester, Minn., and published in Journal of Rheumatology in January 2012, tracked surgeries among 813 RA patients from 1980 to 2007. The researchers, led by Eric L. Matteson, MD, found that the incidence of any joint surgery within 10 years of their diagnosis went from 27.3 percent in the 1980 to 1994 period to 19.5 percent from 1995 to 2007. Soft-tissue surgeries declined the most over the period studied, but total joint replacements were down as well. Women and obese RA patients still had more surgeries than men or thinner patients.

In an earlier study published in the journal Annals of the Rheumatic Diseases, researchers supported by the Intramural Research Program at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS, part of the National Institutes of Health) also tracked a group of California RA patients from 1983 to 2007 and found similar declines. Knee replacements for these patients dropped 19 percent over the period and hip replacements dropped by 40 percent.  
 

Not Just a Perception

Having long-term studies that track groups of RA patients over many years makes this decline more than anecdotal, says Joan Bathon, MD, director of the division of rheumatology at Columbia University Medical Center/New York‐Presbyterian Hospital in New York.

“There’s been a perception that surgery has been on the decline, but we haven’t been able to quantify it until now. And it’s not good to make assumptions due to feelings or perceptions,” she says. “But several studies do now suggest that there are fewer surgeries for rheumatoid arthritis patients. The reasons for that are, one, more aggressive treatment of rheumatoid arthritis. If one drug doesn’t work, then we add more drugs. And two, we have a larger arsenal of drugs. We are combining drugs and treating earlier.”

Surgeons also notice the decline in RA patients coming to their offices to seek joint replacements, notes Jeffrey N. Katz, MD, Professor of Medicine and Orthopaedic Surgery at Brigham and Women's Hospital in Boston. “It’s nice to have some scientific data to back it up, but the impressions that you are getting from people in the field is that the biologic drugs are working and reduce the incidence of advanced arthritis, and because of that there is a reduced need for surgery.”  In the past, about 20 percent of the joint replacements performed by his department were related to RA; now they only perform 10 percent of joint replacements on RA patients.

Today, the RA patients needing joint surgery are mostly older patients who developed RA prior to the new crop of drugs coming on the market or people who have not had access to these drugs, including uninsured people and immigrants coming from poor countries where the treatments are not available, says Dr. Katz. He also travels to the Dominican Republic each March to perform joint replacements on many poor RA patients. “We see people with severe, multiple-joint rheumatoid arthritis. It’s a reminder of what this disease can do.”

Orthopaedic surgeons remind us that some RA patients still need joint surgery to correct both soft-tissue damage and either deformed or misaligned joints. “I agree that recent improvements in the medical treatment of rheumatoid arthritis is delaying the need for joint replacement,” says Henry Blum, MD, a surgeon at Houston Orthopedic and Spine Hospital in Houston. “However, if  the knee alignment is too far misaligned (usually too "knock-kneed") from the arthritis, then even if the swelling and discomfort is well controlled with medication, it is better to perform the total knee [replacement] soon.  If the patient waits too long, bone damage can occur, and that would decrease the chance of a successful and long lasting joint replacement.”
 

Improved Arsenal

Doctors now have many different weapons to fight inflammation in RA. In 1988, the disease-modifying antirheumatic drug methotrexate was approved for RA and became widely used by late 1990s. It’s still the standard first-line drug used to treat RA inflammation, says Dr. Diri.

“It’s probably the best risk/benefit drug for rheumatoid arthritis at this point, and my number one drug,” he says.  Still, if he doesn’t see results after about two months, biologic drugs – the first of which, etanercept, was approved for RA in 1998 – are added. This is a big change from the approach to RA in the past, when doctors might wait several months to see if drugs were fighting inflammation – a period when irreversible joint damage might occur, he says. “Now, patients who are diagnosed with rheumatoid arthritis start with methotrexate and we get the biologic on board if they don’t respond. We don’t hang around too much anymore.”

All of the biologic drugs work in about half of RA patients, so rheumatologists can switch the patient to another treatment if one isn’t working, says Dr. Bathon. And because the drugs are more effective and are being used earlier to fight RA inflammation, we no longer see the need for multiple joint surgeries in these patients, she adds. “People quite often had hand surgery, foot surgery, shoulder replacements, knee replacements. When weight-bearing joints were affected by RA, it was even more life-changing. If you can’t work because your hips are bad or your knees are bad, you’re on disability,” she says. However, the new array of drugs to fight inflammation, including oral, infused and injectable biologic drugs, work well enough to offer people with RA a greater chance at a normal life, she says.

The challenges for rheumatologists now include educating primary-care physicians and medical students to recognize the signs of RA early so patients can be referred for aggressive treatment before joint deformity can take place, says Dr. Diri. “When I observe students doing a rotation with me, when I mention even something like an anti-CCP (anti-cyclic citrullinated peptide antibody) test, they say, ‘Oh, is that new?’ And this student, in a few months, will be a physician! If they’re not educated about the new things in rheumatology, then they think that they can manage RA with NSAIDs or 5 to 7.5 milligrams of methotrexate a week, delaying appropriate treatment of the patient.”

In addition to better education of rising doctors on the possible signals of an RA diagnosis, rheumatologists are focusing on more effective, precise tests to not only determine RA early, but figure out which drug treatment will work best on each individual patient, says Dr. Bathon. “Research in biomarkers is key. Is there a genetic polymer? Is there a particular protein marker in the blood? That’s where the field is heading.”

Meanwhile, surgeons are seeing fewer patients with “runaway inflammatory disease” coming to see them for procedures because the current drugs work so well, says Dr. Katz, who says he sees far more osteoarthritis patients nowadays due to earlier diagnoses in that population. “The more aggressive strategy is associated with better outcomes. It’s a happy story.”