Guest: Dr. Ara Dikranian
Presenter: Neal Howard
Guest Bio: Dr. Ara Dikranian has been with SDAMC since 2004. He received his Bachelor of Science degree in psychobiology in 1991 and his medical degree in 1995, both from the University of Southern California. He is the current chair of the Arthritis Foundation San Diego chapter advisory board and volunteers his time for uninsured patients through the San Diego County Medical Association Foundation Project Access program.
Segment overview: Dr. Ara Dikranian of San Diego Arthritis Medical Clinic, and member of the RA NarRAtive Advisory Panel, discusses what’s next for the RA NarRAtive Initiative, supported by Pfizer.
Health Professional Radio – The Future of RA Treatment
Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, thank you so much for joining us on the program today. Pfizer recently announced new results of its Global Rheumatoid Arthritis Survey which assessed the quality of physician-patient communication and its relationship to overall RA disease management. The survey involved more than seventeen hundred rheumatologists in 15 countries and demonstrates disconnects between patients and physicians across multiple aspects of RA disease management. Our guest in studio today is Dr. Ara Dikranian of the San Diego Arthritis Medical Clinic, a member of the RA NarRAtive Advisory Panel, here with us to talk about the future of rheumatoid arthritis treatment, management and the NarRAtive Advisory Panel itself. Hello and welcome to health Professional Radio Dr. Dikranian.
Dr. Ara Dikranian: Thank you Neal, it’s a pleasure to be here.
N: Thank you. The study, a survey that was conducted of 15 countries survey, September of 2014 concluding in January of this year. Talk about this survey, why it was conducted in so many countries and what were some of your findings?
D: Certainly. So the RA NarRAtive as a survey is known is really an international initiative aimed at elevating the important role of the patient in the successful management of rheumatoid arthritis. Pfizer as you mentioned has sponsored this initiative and it’s supported by an advisory panel that’s comprised of health care providers, patient group leaders as you mentioned 17 countries. And really the ultimate purpose of it is to elevate the voice of people who are living with RA and to improve disease management through harnessing the experience of people with RA, health care professionals and patient advocates to try and find solutions that break down communication barriers, create positive change within the RA community. And as you mentioned the key findings of this survey really identified gaps in the not just the management but in communication skills and goal settings as it relates to the management of RA.
N: Now obviously for this survey to even be conducted in the first place there must be some level of dissatisfaction on the part of the patient receiving the care and on the part of the physician who is obviously seeing some results that should not be manifesting based on the treatment that they’re giving. Why do you think that there is this dissatisfaction? What is the root cause based on the survey findings?
D: Certainly. So the dissatisfaction sometimes goes unrecognized or unspoken and I think that’s one of the key findings is that patients often don’t feel empowered or confident to voice their concerns if their treatment goals aren’t being met. So patients may have obviously comorbidities that will contribute to the symptoms of rheumatoid arthritis, so we know that patients who have rheumatoid arthritis are for example have an increased risk for depression, so we need to tease out what exactly is bothering the patient and…appropriately manage that aspect of it. The part of physicians, the disconnect with dissatisfaction really is in noticing the advent of many neuro-therapies, very focused in effective therapies that’s the last 15 years has shown and recognizing that despite this advances we still are not close to achieving the numbers of patients who are achieving remission of this disease. We all recognize that there’s no cure for rheumatoid arthritis but these therapies despite being effective are not achieving sort of the as many satisfactory results as we wish and therefore, so we’re trying to identify is there a more that we could be doing in cooperation with the patient to try and best manage the disease in those who have it.
N: Okay, so you have a patient who is effectively taking control of their RA management, discussing things with their provider. What about different priorities? Maybe the patient’s priority is pain where the physician’s priority maybe something more long term. How do you align management priorities to where the treatment is the most effective?
D: Yeah, of course it’s a very good point and really one of the aspects is that we have guidelines that rheumatologists will use to treat rheumatoid arthritis but various medications and we have ways of measuring disease activity that’s based on objective measures, laboratory values, the numbers of swollen joints, etc. and all of that is really focused on achieving remission based on those objective values. However as far as a patient’s concern often times they don’t know or they don’t understand why the numbers of swollen joints or inflammatory markers on their laboratory’s being elevated are important, so they come into the discussion with knowing that their function is not improving as much as they like, that their pain is still there that perhaps they’re having side effects from medications which may not be tolerable. So there are various gaps that have been identified in this survey that really focus on exactly that, that the definition of treatment success and the disease management that’s based on really varies from physician to patient.
N: Talk about the progression of the disease and how it affects communication between the patient and the provider.
D: Yeah, that’s a very important point because we know that patients with very early disease who have a lot of symptoms, who have anxiety about not knowing what’s going on or being diagnosed with the chronic condition that they’ll have for the rest of their lives, really want to get back to as normal state as they remember prior to the onset of the rheumatoid arthritis. So the treatment goals for a patient early in their course really focused on education and counseling and really trying to aim at remission, coming as close to, look here as we may have despite the absence of that without the use of medications. As patients progress there’s a new sense of normalcy, there’s a resilience that patients with rheumatoid arthritis have in terms of adapting to some of the difficulties, the challenges of range of motion in their joints. So there’s this new sense of normal, unfortunately sometimes this new sense of normal is translated to just settling, so patients settle for whatever treatment that they’re on, not perhaps wanting to or not being offered the chance that perhaps different management plan might improve, might improve their condition significantly or even somewhat. So really bridging that disconnect with communication as the disease progresses and really not trying to settle particularly in those who’ve been managing their disease chronically not maybe thinking that there might be better options for them out there.
N: Your survey was conducted in an age group 18 plus. This disease seems to manifests itself between 40 and 70 although I’m sure with almost four thousand people in 15 or more different countries being surveyed, you came across some young people, 18 or close to 18, early 20s and 30s who’ve been diagnosed with RA at different stages. What about the mindset of those who are diagnosed at an earlier age as opposed to those who are diagnosed later in life? Did you find any type of pattern there or anything that could help us as far as the future of RA management goes?
D: Yeah, that’s a very good point and a very important one to recognize that it’s not just adults who get inflammatory arthritis or rheumatoid arthritis but kids as young as a few months old to few years old can start developing symptoms that are just like rheumatoid arthritis. In fact there’s a whole management of pediatric rheumatology for juvenile inflammatory arthritis, what used to be called juvenile rheumatoid arthritis. And obviously this survey did not focus on kids or on patients with RA who were younger than 18 but you’re absolutely right and that segment would have a completely different management plan and treatment goals than adults would. The next step in looking at the RA NarRAtive is really focusing on some of the country specific differences and some of the age who are gender specific differences that would try and identify people who might have the different mindset and seeing if there any differences that we might tease out as it relates to age or gender or even duration of disease.
N: Well Doctor it’s been a pleasure talking with you today and hoping that you’ll come back in some future segments and talk with us.
D: I would love to do that Neal. Thank you, I appreciate the opportunity to be here.
N: You’ve been listening to health Professional Radio, I’m your host Neal Howard. And we’ve been in studio talking with Dr. Ara Dikranian, member of the RA NarRAtive Advisory Panel and we’ve been in studio discussing the future of rheumatoid arthritis treatment and patients taking control of their RA management. Transcripts and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm and you can subscribe to this podcast on iTunes.