Rheumatic disease research and implications for clinical care

Abstract

In the past decade, it has been discovered that the pathogenic processes that underlie rheumatic disease start years before the clinical diagnosis is made. In rheumatoid arthritis (RA), for example, specific autoantibodies and elevated cytokine levels are detectable in the blood for several years prior to diagnosis (1, 2). The same has been found in systemic lupus erythematosus (SLE) (3) and Sjögren’s syndrome (4) and is thought to occur in most autoimmune diseases. Meanwhile, clinical trials continue to demonstrate that the earlier patients with rheumatic diseases, including RA and ankylosing spondylitis (AS), are diagnosed and treated, the better they will do (5, 6). Irreversible joint damage and destruction and the long-term risks of cardiovascular disease and osteoporosis decrease with prompt, responsible and aggressive treatment with disease-modifying therapy. However, while the mortality gap between patients with rheumatic disease and those without continues to grow (7), there is still a significant delay in the recognition and treatment of patients with rheumatic disease (8). Unfortunately, the gap in care appears to be at the level of the general practitioner. The disease is often not recognised, patients are offered ibuprofen or prednisone only, and/or they are not referred to specialists in a timely way (9, 10). Efforts are now being directed at the education of generalist physicians about the recognition and care of rheumatic diseases, and ‘5 minute’ rheumatic disease consultation clinics have been set up in some cities to increase access to rheumatology specialists. New criteria for the diagnosis of RA have been developed in a joint effort by the American College of Rheumatology and the European League against Rheumatism (11, 12). Recommendations for referral of patients with suspected AS and RA to rheumatologists have been developed for generalists (13, 14). But why does this gap in care exist and why are generalists unaware of the need for early diagnosis and aggressive therapy for RA and other autoimmune diseases? Let me point out that all of the literature cited above has been published in subspecialty rheumatology journals. Vanishingly little of these important recent studies in rheumatic disease, enabling earlier diagnosis and demonstrating the importance of prompt and aggressive therapy, have been published in the general medical literature. Let’s face it: general practitioners never have had and never will have the time to read all of the medical subspecialty journals. The International Journal of Clinical Practice, whose mission is ‘to prioritise and interpret high-quality research for clinical practitioners since 1957’, could play a tremendously important role in bridging this divide. With a wide and diverse readership including generalist and all types of specialist physicians throughout the world, IJCP is perfectly poised to communicate important research findings and concepts, in particular those with implications for clinical practice, to the medical world at large. It is imperative for the relatively small rheumatology research community to disseminate its findings to this greater medical community. How better to do this than through publication of clinical and basic science findings, together with editorials and reviews interpreting these findings, in a journal read by medical practitioners the world over? Improving the evidence-based care of rheumatic disease patients is the ultimate goal of research in rheumatology, and it is time to start getting the evidence from recent clinical and basic studies in the rheumatic diseases to those on the front lines. None.