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Experts at Odds on Rheumatoid Arthritis Treatments

Hand surgeons and rheumatologists disagree dramatically, survey finds

(HealthDay is the new name for HealthScoutNews.)

FRIDAY, Aug. 1, 2003 (HealthDayNews) -- There are many treatments for rheumatoid arthritis, including medicines to reduce inflammation and hand surgery to restore dexterity.

But how do you know what's best for you?

It's tough, say doctors at the University of Michigan who report in a new study that the two groups of specialists who treat the ailment --rheumatologists and hand surgeons -- are miles apart on what provides the best results for an individual.

"We have two groups of physicians who have had intensive training and are not in communication with each other and who are in complete disagreement with each other on the management of rheumatoid arthritis," says lead author Dr. Amy Alderman, a resident surgeon with the University of Michigan Health System in Ann Arbor.

The results of the study appear in the August issue of the Journal of Rheumatology. In addition to Alderman, the authors include a rheumatologist, a senior hand surgeon and a general internist.

Alderman and her colleagues surveyed 1,000 rheumatologists -- who often get the initial patient referrals and tend to favor medications -- and hand surgeons. The researchers found there's little sound clinical data on results for different surgical treatments, that both groups of specialists don't read literature in the fields outside their specialties, and there's little consensus among the specialists on the best way to treat rheumatoid arthritis.

The result: Patients can be left in the lurch when it comes to managing their care.

Rheumatoid arthritis affects about 2 million Americans, mostly women, according to the American College of Rheumatology. It can cause painful and debilitating inflammation and deformities in joints and tendons, especially in the hands and wrists. Triggered by an autoimmune malfunction, the disease is most often treated with medicines to reduce the inflammation.

But hand surgery can be an option for patients who don't respond to the medicines or whose hands have become too twisted to perform daily activities.

Sufferers usually seek advice from their primary-care physician. And that, Alderman says, "puts the primary doctor in a difficult position because he or she doesn't have the training to make an informed decision. The two specialists (a rheumatologist and a hand surgeon) need to get together and get a consensus."

Dr. Peter Gorevic is head of the rheumatology department at Mount Sinai Hospital in New York City. He says the new study "acknowledges a problem that needs to be addressed. The authors have identified differences between the two sub-specialties. But it's not proven whether that leads to problems in patient care or if it's the reason for the significant disabilities associated with the disease."

Dr. Steven Z. Glickel, a hand surgeon at the Starr Hand Surgery Center at St. Luke's-Roosevelt Hospital Center in New York City, says he was shocked by the study's conclusions because, in his own practice, he feels the rheumatologists and surgeons work well together in treating patients.

"I thought all that had changed. In my practice, I deal with two or three rheumatologists on a fairly regular basis, and they will send patients to me at an appropriate time for surgery. It's not a big issue," Glickel says.

For Alderman's survey, doctors filled out questionnaires on treatment options for the disease, and offered their views about each specialty. The responses revealed wide variances in care for rheumatoid arthritis, depending on where patients lived, the type of physician they were referred to, and what that doctor personally thought of other specialties.

One question asked when the doctors would turn to surgery for a patient with swelling around the tendons on the back of the hand, a condition called extensor tensynovitis. It weakens the tendons and can lead to tendon rupture, which would limit a person's ability to extend his or her fingers.

Alderman says the recommendations varied significantly between the hand surgeons and rheumatologists. The surgeons recommended surgery within three to six months if aggressive medical management -- drugs -- failed. But the majority of rheumatologists said surgery should be postponed for up to a year or longer -- or never done at all -- to see if medications were effective.

"These are completely opposing opinions," Alderman says.

Further, the authors found rates of surgery vary tremendously from state to state, with some states reporting rates fourfold higher than others.

"There is no consistency as to whether the procedures work and when to do them," Alderman says. "I hope that this study will make people aware of the controversy so we can get more funding and answer these questions."

Alderman says other diseases benefit from a multi-disciplined approach among doctors with different specialties, and that treating rheumatoid arthritis should be managed the same way. In breast cancer, for instance, a medical oncologist, a surgical oncologist, a reconstructive surgeon and a radiologist all work together to devise a treatment plan for a patient.

Glickel, who wrote an editorial that accompanied an article that appeared about the study in the January issue of the Journal of Hand Surgery, says the best solution for patients is to be reasonably educated about the options open to them.

"If they're aware that surgery does exist for their condition, they can bring it up with their rheumatologist," he says.

More information

The Arthritis Foundation lists the drug treatments available for rheumatoid arthritis. It also has information on surgical options for treating the disease.

SOURCES: Amy Alderman, M.D., M.P.H., University of Michigan and University of Michigan Medical Center, Ann Arbor; Peter Gorevic, M.D., head, rheumatology, Mount Sinai Medical Center, New York City; Steven Z. Glickel, M.D., Starr Hand Surgery Center, St. Lukes-Roosevelt Hospital Center, New York City; August 2003 Journal of Rheumatology
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