John Cush, MD: How Early is Too Early to Diagnose and Treat Rheumatoid Arthritis?

Rheumatology Network interviewed John Cush, MD, to discuss his CCR West presentation “Rheumatoid Arthritis: How Early is Too Early to Diagnose and Treat?” Cush is the Executive editor of RheumNow.com. We discuss the main points of his lecture, preclinical rheumatoid arthritis (RA), and issues with patient delay.

Below is a preview of our conversation:

John Cush, MD: “The mantra of the rheumatologist is diagnose RA early treat aggressively. I believe that everyone believes that to be true. I think rheumatologists are aggressive at managing rheumatoid arthritis. However, I think rheumatologists are totally out to lunch when it comes to early diagnosis. We've missed the opportunity. Rheumatologists haven't changed the paradigm by which patients are referred; we don't market ourselves. They passively see patients that are referred to them. And the data is still pretty clear: from symptom onset to rheumatologist refer, seeing the patient can be really quite long, usually more than 6 months, and maybe in some instances longer than a year.

“The problem with referral is patient delay in seeking medical attention. Primary care says, ‘I can't get a rheumatologist to see my patients.’ Further substantiating that one, [they say] there's too few rheumatologists and rheumatologists haven't reached out for the referral.

“I spent much of the 2000s lecturing about the success of treating earlier but it never changed anyone's practice because to really revamp and see patients earlier, you've got to change the business model. The only rheumatologists who see patients early are the people who see patients within the first week.

“If you can prevent RA, you don't need to treat early RA. It is far easier, and maybe more cost effective, to treat preclinical disease than it is to wait until they have established disease that has been bounced around through a bunch of primary care doctors who didn't know how to manage it or through people who are not [treating] aggressively and then finally come to you and they're already a train wreck. All the damage has been done. It makes more sense when you can probably have more impact in either delaying, stalling, or stopping the progression to disease.”