COMMENTARY

10 Rheumatology Advances From 2016

Kevin D. Deane, MD, PhD

Disclosures

December 19, 2016

There were numerous important advances in clinical rheumatology in 2016. Here, I review 10 items that I feel were most significant to the field, as well as a few other odds and ends that may affect rheumatologic care.

1: A Looming Rheumatologist Shortage in the United States

Perhaps the most sobering news in rheumatology in 2016 was the release of the American College of Rheumatology (ACR) 2015 Workforce Study.[1] The gist of this comprehensive assessment of the workforce issues facing rheumatology in the United States is that by 2030, there will be too few rheumatology providers to meet the needs of patients.

The ACR is now looking hard at a variety of ways to increase the workforce; these include increasing recruitment and support of physicians at all stages of training, as well as expanding involvement of nurse practitioners, physician assistants, and other providers. In addition, ways to improve practice efficiency and increase the role of primary care are being considered. This is a critical issue, and let us hope these methods are effective so that patients' rheumatology needs can be met in the years to come.

2: Tapering Therapies in RA

There is growing evidence that some patients with rheumatoid arthritis (RA) may be able to taper their therapy and yet maintain good disease control; however, this does not work for all patients. As discussed in an excellent review on the subject by Schett and colleagues,[2] several features that suggest tapering may be successful are "deep" remission, as evidenced by sustained remission for at least 6 months on stable disease-modifying antirheumatic drugs (DMARDs); very low scores on disease activity measures (eg, Disease Activity Score in 28 joints < 2.6); absence of synovitis on imaging; normal inflammatory tests; and negative autoantibody tests. Of note, in most studies to date, if flares do occur with tapering, disease can usually be brought back under control by restarting therapy.

More research is needed to find broadly applicable metrics that will identify which patients can successfully taper therapy, but it is encouraging that this can actually be a research goal in RA.

3: New Classification Criteria for Sjögren Syndrome

In a combined effort, the ACR and European League Against Rheumatism (EULAR) developed a classification scheme for primary Sjögren syndrome (SS).[3] The final criteria were arrived at by data-driven consensus, and are a weighted sum of five items:

  • Anti–SS-A/Ro positivity (score of 3);

  • Focal lymphocytic sialadenitis with a focus score ≥ 1 (score of 3);

  • Abnormal ocular staining (score of 1);

  • A Schirmer test ≤ 5 mm in 5 minutes (score of 1); and

  • Unstimulated salivary flow < 0.1 mL/min (score of 1).

Individuals with signs and symptoms of SS who have a score of 4 or greater meet the criteria. In initial testing, these criteria performed well, with 96% sensitivity and 95% specificity. More testing is needed, but as the authors state, these criteria should improve clinical trials for SS.

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