Rheumatoid arthritis

Telehealth a barrier to treat-to-target strategies for RA patients, clinicians warn


The switch to telehealth services to manage patients with rheumatoid arthritis may turn back the clock on improvements in patient care made through treat-to-target strategies, UK clinicians have warned.

Restricting face-to-face clinics to patients who have a disease flare may miss patients with ‘stable disease’ who have low to moderate disease activity but whose condition has not got worse, the team from University College London point out.

Writing in an editorial in The Lancet Rheumatology, Professor Michael Ehrenstein, a Consultant Rheumatologist, said treat-to-target strategies require frequent monitoring by clinical examination and blood test – particularly in the early disease phase.

His article raises concerns over whether the telehealth remote consultations that have become the norm since the start of the COVID-19 pandemic are compatible with treat-to-target strategies.

And the challenges in providing care in a post-COVID-19 world create further barriers to wider adoption of treat-to-target protocols and are likely to lead to fewer rheumatoid arthritis patients achieving remission, he added in the piece written with co-author Dr Su-Ann Yeoh.

Similar problems are apparent with dose tapering where patients need to be carefully monitored to identify signs of disease worsening. Some patients may have stopped medication or attempted to taper their dose over concerns about the risks of COVID-19 infection, the editorial states.

The pandemic does provide the opportunity to research patient-reported outcomes and web-based monitoring apps being used in remote management but these measures cannot replace clinical examination, Professor Ehrenstein said.

Instead creating multidisciplinary, one-stop-shop face-to-face clinics might, in the long term, reduce hospital visits by patients.

“Treat-to-target and safe tapering strategies should continue to be essential in the management of rheumatoid arthritis, regardless of new approaches that streamline the patient experience and reduce the number of hospital visits.

“Patients with rheumatoid arthritis on minimal or no DMARDs and in sustained remission might be candidates for remote consultation,” the editorial concluded.

“However, certain terms, such as stable or well controlled, should not be used in the lexicon of rheumatology practice without reference to the maintenance of remission, nor should patients with stable moderate or low disease activity be forgotten.

“Amid the flurry of creating the new normal, patients with rheumatoid arthritis should not have to turn to increasing their dose of non-steroidal anti-inflammatory drugs as joints slowly erode, reminiscent of the dark days of rheumatology in the 20th century when stable disease was an acceptable target.”

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