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Living in interesting times: insights from APLAR

Editorial Commentary

May you live in interesting times: this wry saying is usually said to originate in China, although at least according to Wikipedia, it probably doesn't. This year, the 18th Asia Pacific League of Associations for Rheumatology Congress (APLAR) took place in Shanghai and was attended by rheumatologists from all over the world. We sent a reporter out to the conference to ask some of the attendees to highlight take-home messages for the practising rheumatologist and to discuss recent developments from a global perspective.

Comorbidity and treatment choice in RA

One of the main themes we'd identified at EULAR was comorbidity. APLAR also had sessions on comorbidity.
In his interview Prof Ernest Choy discusses the importance of comorbidity in RA: if you don't think of it, you don't look for it: for example, patients with RA may have "silent" angina and often already have cardiovascular disease by the time they first present to the rheumatologist. The presence of interstitial lung disease, as a risk factor for infection, can also make an important difference to treatment choice in RA.

In this context, smoking is highly relevant to many RA comorbidities, including interstitial lung disease as well as cardiovascular disease. In much of the Western world, nearly as many women as men are smokers now. In many parts of the Asia Pacific region, by contrast, smoking is much commoner than in the UK, and still mostly done by men. Passive smoking both at home and in the workplace is still a major public health issue in China and elsewhere. Thus, it’s important to highlight the opportunity of including smoking cessation as a key aspect of comprehensive RA patient management, which may also assist in helping patients to achieve low disease activity/remission with lower risk of treatment side effects.

Prof Iain McInnes also discusses the approach of treating the "whole patient" rather than just one disease. Each patient is an individual with her/his own particular pattern of disease and comorbidities against a unique genetic background. Patients also have information needs: explanation and education is crucial and can build trust. Choosing the right medication isn't enough; treatment strategies, such as treat-to-target, have been shown to bring additional benefits. As new drugs for RA appear on the horizon, there will be a continued increase in the number of possible sequences or combinations of medications. He also discusses the potential role for precision, personalised or stratified medicine in future treatment of RA. It seems plausible that perhaps the sort of datasets generated by multiple -omics technologies might inform the optimal selection of treatments. It remains to be seen, however, exactly how this would work in clinical practice.

In related content (APLAR-ARISE), Prof McInnes describes a collaboration between UK RA Center for Excellence and Chinese rheumatologists (Prof Mengtao Li and colleagues) called ARISE. As a result of this collaboration, Prof Li conducted an observational study evaluating whether prolonged intensive disease-modifying antirheumatic drug (DMARD) treatment (PRINT) with methotrexate, lefunomide and hydroxychloroquine leads to high remission and low relapse rates in patients with severe rheumatoid arthritis (RA). Indeed, this treatment resulted in 40-50% of patients achieving good EULAR response, and patients who achieved remission could taper therapy without relapsing, being maintained on leflunomide. Results are now published in Medicine 2016 Jul; 95(28): e3968. Such a study and others like it will provide guidance in RA treatment selection for practicing rheumatologists in China.

Prof Tom Huizinga also discusses the importance of treating to target in rheumatoid arthritis, and adds some tips on how one might personalise treatment choice using the sort of clinical data we already collect as a matter of routine.

Rheumatology in a world of global connectedness

In his interview Prof Hans Bijslma introduces some of the philosophies behind EULAR, including international co-operation and the importance of patient involvement. He also discusses the new EULAR School of Rheumatology, which will be a platform providing high-quality educational resources for healthcare professionals and the public across the world.

Prof Tony Woolf takes an international perspective in his interview, discussing development of the international workforce, including innovative use of "first-responders" trained to identify potential inflammatory arthritis and refer on to specialists. He also talks about cultural differences and the importance of educating patients about taking modern evidence-based treatments in rheumatology.

Finally Prof Peter Brooks talks virtual health and the future of medicine: already patients are using the internet to access medical services - this might be particularly beneficial for those who are isolated geographically or due to mobility restrictions. The internet can be a powerful source of peer support; many thriving patient communities already exist. There has been a culture shift from the old paternalistic model of care to a participatory model based on shared decision-making giving the patient the role of prime decision-maker.  

Feeding the algorithms: where are we going?

The implicit idea of medical care as something done to a patient is now evolving into a model in which the patient is fully engaged, or at least as engaged as they want to be: "nothing about us without us". Advances in outcomes science means that patients are now co-creators of their own medical record: patient portals to the electronic healthcare record may allow us to integrate patient-reported outcome data into everyday clinical practice, collected across time and space rather than just during admissions or on the day of a clinic visit.

Traditionally "research" and "clinical practice" have been separate endeavours, practised by separate communities of people and with regulatory oversight provided by different entities. But databases are no longer the sole preserve of researchers. In the wider world, the choices we are offered are increasingly determined by complex algorithms. Our personalised news feeds and the advertisements we see are merely some of the more noticeable effects of this trend, but other, more insidious potential effects include differential access to consumer products such as credit and insurance. Will algorithms also determine the choices patients are given? Is "personalised medicine" just an exciting way of saying algorithm-informed medicine, or is there really more to it than that? And what data should we be feeding to these algorithms? How will "big data" influence the types of conversation we have with patients by the year 2025? We live in interesting times indeed.

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