A View of Rheumatology From 31 Years And 30,000 Feet

A View of Rheumatology From 31 Years And 30,000 Feet Posted By:
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The last 31 years of my PA career has been in the subspecialty of rheumatology. As I reflect on the changes in the field, I have become aware of the incredible transformation that I have had the good fortune to witness. In 1988 I was injecting IM Solganol (injectable gold, considered state-of-the-art treatment) for our patients with rheumatoid arthritis, and then witnessed the adoption of methotrexate, which continues to be the drug of choice for those newly diagnosed. A quantum leap occurred with the introduction of tumor necrosis factor (TNF) inhibitors in November of 1998 with the release of Enbrel. Then four more TNFs were introduced over the next 11 years, giving us more options for our patients. Next was T cell and B cell targeted therapies, followed by interleukin (IL)-6 inhibitors Actemra (2010) and Kevzara (2017). Our latest entry in to the market has been JAK inhibitors with the entrance of Xeljanz (2016), and last year with Olumiant (2018). These oral agents have excellent response rates, and are preferred by many patients.

In the osteoporosis world we have advanced from Didronel (which has been discontinued in the US, but is still available in Canada), a non-nitrogen containing bisphosphonate, to Fosamax, Actonel, Boniva, and Reclast, all of which are nitrogen-containing and have longer residence times in bone and thus increased potency. Our first anabolic agent, Forteo, was approved in 2002, and Tymlos in 2017, both of which can transform skeletons and dramatically improve fracture risk. Now, just this week, we see the launch of Evenity with a novel mechanism that purports to be both anabolic and anti-resorptive for those with high risk for fracture.

Our patients with psoriatic arthritis have been enjoying targeted IL-12/23 therapy with Stelara (2009), IL-17 inhibitors Cosentyx (2016), and Taltz (2017) with over 90% clearance of skin and significant improvements in joint pain, stiffness, and swelling. These are remarkable biologic targeted therapies and there are more on the way.

The ever increasing and expanding market of new drugs with novel mechanisms is exciting on the one hand, and challenging on the other, especially when it comes to deciding when to deploy these medications in an individual patient. One of our biggest barriers is being able to get these costly medications to our patients in a timely and cost-effective manner.

Lastly, rheumatology has been one of the many subspecialties with a concern over manpower shortages. As a PA who is on the "exit ramp" to retiring from my clinical responsibilities, I encourage my NP and PA colleagues to consider this growing and exciting subspecialty. It has treated me well over the last 31 years.


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Filed under: Rheumatology

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