Once a month, the local rheumatologists meet at our tertiary level, teaching hospital to discuss challenging cases. We invite the patients being discussed to attend. Usually, there's a question being asked, a problem to resolve or sometimes, it's just cathartic for the patient and treating rheumatologist to efficiently get a range of opinions.
It was my turn.
My patient presented when she was 30 with an abrupt onset of rheumatoid arthritis. More than 20 joints swollen and inflamed, high inflammatory markers, very high autoantibody levels (both RF and anti-CCP). She was struggling to cope with daily life.
Bad disease. By any definition.
Over 6 years, I treated her with a variety of medications: Methotrexate, Prednisone, intra-articular steroid, Arava. Within 10 months of her symptoms, she was on biologic DMARD therapy. She has trialed Humira, Actemra, Orencia, Enbrel, and is now on Mabthera.
She has responded and is of course better than when she presented. But she has never entered sustained remission.
It's hard to tell that she has rheumatoid when you meet her.
She doesn't have the classical hand deformity. Her MRI of the hands do not show any active disease or erosive change affecting the fingers.
When you feel the swelling at both her wrists, see her wince a little, and note that she has lost a lot of movement at these joints, you then understand that the disease has caused damage and it's still affecting everything she does.
I presented her to see if the others could think of anything else to improve the situation.
Among the 6 rheumatologists present, there was over 100 years of clinical experience.
The consensus was that we had done well. A patient presenting the way she did, would in a previous era, be riddled with arthritis and deformity by now. She would very likely not still be working full time.
That might be true but I still feel that we should have done better. Rheumatologists are continuing to strive for better and better outcomes for our patients with rheumatoid arthritis.
The goal posts have moved, and during my career, I expect them to move much further.