Dr. Hyman Tannenbaum
bh IN BRIEF
Arthritis can severely affect ability to work, and the activities of daily living…and not just for older Canadians. Most patients are “resourceful and motivated”, but need timely access to specialist care. Rheumatologists have a deep understanding of the various therapies, and can also better navigate the system, for example, by helping their patients complete special authorization forms for “tremendously effective” biologic products. Patients can also help themselves by losing excess weight, and ensuring their mobility equipment is properly fitted. Employers can play a supportive role by allowing appropriate access to the necessary drugs, and providing adequate physiotherapy coverage.
The stories about COX-2 inhibitors, a type of non-steroidal anti-inflammatory drug (NSAID) first introduced in 1999, are well known. Welcomed by patients, but generally over-prescribed, the drugs became the poster children for runaway drug costs, and eventually, patient safety. Lost in all the attention given the drugs were the needs of those suffering from arthritis. New Canadian guidelines, introduced for all NSAIDs earlier this year, attempt to balance the interests of patients in getting effective relief from pain and inflammation, with safety concerns associated with hypertension and impaired kidney function.
businesshealth spoke to Dr. Hyman Tannenbaum, a rheumatologist and the lead author of the new guidelines, about arthritis treatments and the impact of arthritis on his patients’ lives.
1. What’s the impact of moderate arthritis on the activities of daily living?
There are several kinds of arthritis [see preceding article], and the effects depend on the type. If left un- or under-treated, pain and deformities caused by arthritis may affect daily functions, particularly in the morning. Routine tasks can become tortuous, and work that requires manual dexterity, flexibility or strength will be considerably more difficult. A rheumatologist, if you can see one, can have the most impact if they see a patient early. Fast access to therapy can prevent disease progression.
“I find most patients are resourceful and motivated”, Dr. Tannenbaum says. “They tend to accommodate and improvise, particularly younger patients with RA who have family responsibilities. They get up earlier to make the kids’ lunches.”
2. Do medical specialists have different approaches to managing arthritis?
Dr. Tannenbaum believes there is often a big difference between family practitioners (FPs) and specialists. FPs tend to use different, lower-level drugs such as analgesics, NSAIDS, and DMARDS (Disease Modifying Anti-Rheumatic Drugs). FPs don’t generally prescribe biologics due to lack of familiarity, and because special provincial application forms and criteria are required to achieve reimbursement. These criteria are not well known to FPs.
3. Can you elaborate on how excess weight and exercise can affect arthritis?
Of all treatments, the first and most effective would be to lose weight. This means less stress on joints, and therefore, less inflammation and pain. Patients can actually avoid drugs. He encourages patients to exercise, cutting back or stopping only when inflammation and pain occur. Dr. Tannebaum says inactivity will not prolong the lifespan of a damaged joint. He also recommends use of a properly fitted cane to offload the pressure and weight from a damaged hip or knee. He recommends patients purchase a cane from a specialty store that can properly adjust the length of the cane and teach the patient how to use it appropriately.
4. How have biologic treatments affected treatment for arthritis?
When biologics are prescribed, it is because patients are no longer benefiting from other DMARDs. Biologics are prescribed earlier now to prevent joint damage, but standard DMARDs, such as methotrexate, should be provided first.
“As a last resort, the biologics are tremendously effective drugs. In effect, we can rehabilitate patients without surgical intervention: we are almost talking of a cure here. Over 70% of patients taking biologicals respond very well, and remember these are the worst-case situations where other medications are no longer working.”
Dr. Tannenbaum notes that there is evidence that combining three DMARDs can provide the same effects as a biologic. This treatment is rare in North America, and requires the patient to take alot of pills, so a biologic may be preferred if third-party coverage exists.
5. How could employers help prevent or reduce the effects of arthritis on both patients, and their business operations?
Employers have to be aware of health system limitations. Unfortunately, long waiting times in Québec and elsewhere still delay access to specialists and surgery. Other parts of the recovery process, like pre-operative physiotherapy and rehab, can also be very difficult to access. Private insurance coverage for physiotherapists is very important. They can give advice to improve quality of life, which helps keep patients in better shape until they can be seen by a specialist, and also helps them heal and return to work faster.
Dr. Tannenbaum suggests reimbursing biologics can provide good value to employers. In the short term, biologics affect the disease faster, which means return to work sooner. Over the long run, there is less joint damage and pain for those treated on biologics.
Employers have a stake in this condition, since four in ten of those who suffer from arthritis are under age 65, and disability is the largest part of the economic burden. Implementing health promotion programs can help, because arthritis is associated with obesity, stress, and even smoking, and can be improved with moderate exercise.
Rheumatoid arthritis, though less common, typically affects those in their 30s and 40s, and can progress quickly without medical intervention. Appropriate access to biological drugs can make all the difference to both ability to work and quality of life. Insurer pooling products can help limit plan exposure to these, and other, high-cost drugs. As Dr. Tannenbaum points out, physiotherapy can also help maintain functioning both before and after surgery.