Rheumatoid Arthritis is not a disease confined merely to the joints. While constantly painful, swollen joints cry out for attention and cause impactful disabilities, the chronic, insidious, systemic inflammation paves the way to earlier cardiovascular mortality. The unrestrained spiralling immune dysregulation and various longterm immunosuppressive treatments also cause manifold increase to cancer and infection risks.
RA is is patently not "stoically-grin-and-bear-it" benign.
Multiple comorbidities are associated with RA. In addition to the better known ones like hypertension, heart attack, stroke and cancer, there are pulmonary and hormonal ones as well.
It is speculated that chronic, unabated inflammation underlies them all. If so, and prevention is better than cure, then nipping RA early and decisively at its bud is mission critical.
The Good News is, we now have a slew of highly effective "silver bullet" (targeted) therapies for RA which can rapidly and decisively arrest the disease before it can cause irreparable damage or even entrench itself, and with vastly improved safety profile compared to the older DMARDs and steroids.
The Bad News is that they are extremely costly, putting them beyond the reach of many needy patients. Healthcare economists and patients alike have to confront the stark reality that, there being no free lunches in life, one can choose to bite the proverbial bullet (cost or side-effects) to pay forward now, or to payback in a future rife with disabilities, comorbidities and early mortality.
While the decision whether to pay forward or to pay back rests squarely on the payer's (patient or insurer) shoulders, the rheumatologist can help, not merely to table treatment options with their respective costs, but in cost containment as well.
This can be achieved by:
1) Devising a "Fast-and-Furious" (F&F) "Treatment-to-Target" (T2T) with "Whatever-It-Takes" (WIT) strategy. In WIT, the trade-off is between cost and safety. Either way, the shortest duration of F&F necessary to achieve T2T will ensure the lowest cost/morbidity;
2) Predicting which patients will have rapidly destructive disease and worse outcomes, in order to target the costly and/or potentially hazardous targeted therapies at them. The anti-CCP (ACPA) and RF are 2 such predictive tests.