Late Breaking News
Treating Rheumatoid Arthritis in the Military Healthcare System
- Categorized in: March 2009 Issue
WASHINGTON—Rheumatoid arthritis (RA) is an auto-immune disease that causes swelling of the joints and surrounding tissue. Left untreated, RA can badly damage joints to the point where they no longer function.
While the diagnosis of RA can be devastating, advances in treatment have improved the quality of life of patients, according to Col. David Finger, MC, USA, consultant to the Army Surgeon General on rheumatology and the chief of rheumatology at Tripler Army Medical Center in Hawaii.
“I’ve been in 20 years now and over those last 20 years there has been really signiﬁcant advances in the treatment of this condition,” Dr. Finger said. “People don’t have to look forward to a lifetime in a wheelchair and getting joint replacements and quitting work because of disability. I’ve had people run the marathon with rheumatoid arthritis.”
According to the Centers for Disease Control and Prevention, an estimated 1.293 million adults aged 18 and older had RA in 2005, down from the previous 1990 estimate of 2.1 million. The incidence of the condition is typically two to three times higher in women than men in the U.S.
Dr. Finger said that the prevalence of RA within the military follows that of the U.S. population in general. “The military is the reﬂection of our society at large and the prevalence rate of rheumatoid arthritis is approximately 1 percent in the United States,” Dr. Finger said. “The peak incident for RA is around age 40 and a lot of our troops are in their 20s, so we probably have it a lot less commonly in active duty members, but we see the numbers of dependents of beneﬁciaries really approximates that in the overall community.”
Data from 2008 indicated that there were nearly 7,500 people with a diagnosis of RA seen by a military facility last year, Dr. Finger said.
“This probably under represents the true number because it doesn’t capture those who are seeing civilian [providers] on the outside, but there were nearly 7,500 people with a diagnosis of RA seen by a military facility last year. Of those, about 10 percent were active duty,” he said.
While osteoarthritis is a common arthritis that often comes with older age, RA often starts between the ages of 25 and 55. RA can affect body parts besides joints, such as the eyes, mouth and lungs. It is not a condition that goes unnoticed by those who have it.
“This is not something you can blow off. It is not very subtle. Typically, patients have signiﬁcant joint pain, swelling, severe stiffness in the morning when they wake up. It’s not like you overdid it mowing the yard or cleaning the house and you are kind of sore the next day,” Dr. Finger said.
No one knows what causes RA, though genes, environmental factors and hormones may contribute, according to the National Institutes of Health.
“We know that genetics play a role, but it is not everything,” Dr. Finger said. “If you look at identical twins, if one has RA the other has it about a third of the time. But it is not 100 percent, so we know that genetics is not everything. Most people think that there is some environmental trigger, such as a virus, that, in a person who is predisposed genetically, sets off a cascade of immune responses that ultimately leads to an attack on your body.”
Those who smoke are found to be at increased risk for the developing RA. “People have actually shown that cigarette smoking is actually an increased risk for developing RA,” Dr. Finger said. “If someone already has RA and they smoke, they tend to have more aggressive disease.”
Women who breastfeed for over a year seem to have a lower risk of developing RA compared to those who do not, Dr. Finger added.
Military rheumatologists use the diagnostic criteria available through the American College of Rheumatology in diagnosing RA. In diagnosing the disease, rheumatologists look at several factors.
“Most people with inﬂammatory arthritis, like rheumatoid, will have prolonged morning stiffness and the disease tends to affect the joints in a symmetric fashion,” Dr. Finger said. “It affects both large and small joints. When we do blood work, typically there are antibodies that are present in about 80 percent of patients. Rheumatoid Factor being one and there is a relatively new antibody called CCP (Cyclic Citrullinated Peptide Antibody) and that has a very high speciﬁcity for the diagnosis of RA. Radiographs have been the mainstay for many years, although they are not very sensitive. About 70 percent of patients will have erosion of the bone that you can see on an x-ray in about 2 years. But, newer imaging to include muscular skeletal ultrasound and magnetic resonance imaging are able to pick up inﬂammation and erosion at a much earlier time.”
Improved therapies have helped patients achieve improved outcomes, according to Dr. Finger. Humira (adalimumab) is the anti-TNF agent of choice for DoD beneﬁciaries, which means that a military treatment facility has the option of having it as a formulary item or not. DoD beneﬁciaries can also receive this medication from the TRICARE Mail Order Pharmacy (TMOP) or retail network with prior authorization. Other biologic agents can be obtained through nonformulary drug requests.
“We can obtain other biologic agents for our patients, however, through non-formulary drug requests (NFDR) which are reviewed and evaluated by a MTF clinical pharmacist,” Dr. Finger said.
Future promising agents on the horizon for RA treatment include newer anti-TNF agents such as golimumab and certolizumab and agents that work via different pathways such as tocilizumab, denosumab and oral Janus kinase inhibitors, according to Dr. Finger.
Using Technology to Improve Care
Dr. Finger said that the use of telemedicine has helped military providers help military physicians in other parts of the world care for patients with RA and other rheumatic conditions.
Through this e-mail a military healthcare provider can pose a question to the entire Army group of rheumatologists. Other similar e-mail groups are also managed by the Army for other specialties.
In addition, Dr. Finger said that Tripler has a separate Telepath consultation system in place for Paciﬁc Rim military and beneﬁciaries from remote MTFs and from civilian providers around Micronesia to assist in patient case management.
“Here at Tripler and throughout the DoD we have a system where we get consultations from outlying providers where they present the exam, the x-rays, the labs and we give clinical advice and make recommendations in case they don’t have access to a rheumatologist,” Dr. Finger said.
Dr. Finger said that through the telemedicine program he is able to view clinical exams, the results of labs and view images of patients with RA and related problems.
“I get 1 or 2 [consultations] a day, not necessarily on RA, but on related problems,” Dr. Finger said. “Whereas I do see medevacs from Japan, Guam and Korea, obviously that isn’t the most cost-effective way to practice medicine. So, we have a way here, our telepath system, where they can import digital images and we can access their labs and the result of their examination. We can give guidelines for what other tests we would recommend and that sort of thing.