Interview: Perspective of a rheumatologist
I am Eric-Jan Kroot, rheumatologist for almost thirteen years in the south of The Netherlands. I studied medicine and wrote my thesis about ‘Therapy and outcome of rheumatoid arthritis’ in Nijmegen, at the Radboud University. The treatment of rheumatoid arthritis has always been important to me. This is one of the reasons why I co-founded the rheumatology clinical practice at the Elkerliek Hospital in Helmond, to ensure that patients living in this area get the best rheumatologic care close to their homes.
Helping rheumatic patients
RA is an invisible disease, some people might not even know that they have RA. This also makes the disease very difficult to treat. Early detection and diagnosis of RA are very important, because early treatment can prevent mechanical problems and the chances to get other diseases, such as cardiovascular diseases. The most difficult symptoms to treat in RA are the fatigue and pain. These discomforts can strongly affect the daily life of a patient. Pain and fatigue have to be reduced, to ensure the patients can still work and have a good life.
‘When I just started working as a rheumatologist, patients could end in a wheelchair. Nowadays, this does not happen anymore.’
In the past, the rheumatologist would treat the patient and tell him or her what to do. Nowadays, the patient is treated by a team consisting of nurses, rheumatologists, physiotherapists and other specialists. Furthermore, since internet has become available, patients know a lot about the disease and the treatments, and want to be involved in the decision-making and the treatment. In the future, I think patients will get an even bigger role in the treatment of RA. Here, biosensing can play a crucial role. Patients themselves can measure their medication levels and disease activity, which leads to shared decision-making with the patient and improvement of the treatment.
We usually see patients two to four times a year, but this could be reduced to fewer appointments per year when patients can measure disease activity themselves. More frequent measurements will result in better individualized care. Furthermore, by reducing hospital visits, more patients can be treated by the same number of doctors and nurses.
Diagnosed patients usually start their treatment with classic Disease-Modifying Anti-Rheumatic Drugs (DMARDs) such as methotrexate and prednisolone, which take two or three months before they start working. If the inflammation is not reduced, we increase the prescribed dose. If the disease activity remains high, then a biological drug will be used. About 30% of the patients will use biologicals in their treatment.
An example of a biological is adalimumab, the biomarker of SensUs 2019. Adalimumab is one of the first biologicals that were made. It is the most used drug to treat RA and has been used for almost twenty years, also in other diseases. Patients who use adalimumab usually have less fatigue and less pain, they feel a lot better. In the future, I think it will be very helpful to start the treatment with biologicals such as adalimumab in an earlier stage. Adalimumab is very expensive, but it works more quickly and more frequently than the DMARDs, and has almost no side effects.
‘Optimized dosing is very important, for the treatment as well as for the physical condition of the patient.’
Nowadays, all RA patients who use adalimumab receive the same dose, 40 mg twice a month. This must be optimized since patients do not weigh the same, have differences in the severity of RA and react differently to the same dose, while adalimumab over-dosing reduces the immune system and increases the possibility for having infections. Presently it takes a long time to get measurement results from a laboratory. We would like to know these levels immediately, to be able to change the therapy right away, e.g. when the drug is not effective or when the risk of side effects can be reduced.
‘In the future, it is likely that patients will have a more important role in the treatment. Biosensors can allow patients to measure their own disease activity and levels of medication.’
Biosensors and the SensUs student competition
I like the theme ‘Managing rheumatic disease, by measuring with ease’ of SensUs 2019 a lot, as it is of societal relevance and brings attention to the very large group of rheumatic patients. I think it would be very good if patients could measure their medication and inflammation levels at home. It may be difficult for the most senior patients, but the new patients are more involved with technology at home so they are more likely to embrace a biosensor at home. With biosensors becoming available, we would also get better insight into the patient’s blood levels in the months prior to their hospital visits. In a single visit, we can’t check whether the patient did take the medication all the time and if there has been an increase in inflammation.
What I really like about the SensUs competition, is that the competition is innovative from the bottom up. The teams want to build the best sensor, without being influenced by other parties. I advise the teams to always stay in contact with physicians, to ensure that the sensors they are building will be useful in the daily clinical practice. The teams have to keep in mind that their sensor should optimize the treatment and the patient care.