Summer 2014 (Volume 24, Number 2)

That’s Debatable: The 2014 Great Debate

By Stephanie Ensworth, MD, FRCPC;
on behalf of Vivian Bykerk, MD, FRCPC;
Susan Humphrey-Murto, MD, FRCPC, MEd;
Shahin Jamal, BScPT, MD, FRCPC, MSc; and
Stephanie Keeling, MD, MSc, FRCPC

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The 2014 CRA Great Debate was a standing-room-only event, attended by almost all of the adult and pediatric physician and Arthritis Health Professions Association (AHPA) attendees of the 69th CRA Annual Scientific Meeting (ASM) and accompanied by many partners, spouses, and friends. It did not disappoint! It was a terrific debate loaded with clever humour and spoofs, as well as excellently presented didactic, scientific, and educational material right up to the surprise spectacular finale!

The topic of this year’s Great Debate was “Be it resolved that we are doing too much monitoring of DMARDs and biologics and doing too much screening before initiating biologic therapy.” From the East came Dr. Vivian Bykerk from the University of Toronto and Dr. Susan Humphrey-Murto from the University of Ottawa. Representing the West were Dr. Shahin Jamal from the University of British Columbia and Dr. Stephanie Keeling from the University of Alberta. The team from Eastern Canada argued for the proposition, while the team from Western Canada argued against the statement.

There have been only a few, scattered CRA Annual Great Debates that have included female rheumatologists as debate participants. The 2004 Great Debate featured the first all-female debate of Dr. Claire Bombardier and Dr. Alice Klinkhoff versus Dr. Dianne Mosher and Dr. Janet Pope, all highly respected and highly regarded Canadian rheumatologists. For a trip down memory lane, their debate topic was “Be it resolved that gold is an outdated, impractical, and toxic therapy that no longer has a place in the therapeutic armamentarium for RA.” Since that landmark Great Debate, there has been a dearth of female rheumatology debate participants. This year, 2014, marked the tenth anniversary of that historic 2004 all-female CRA Great Debate and we celebrated by the second ever all-female debate. Again, the participants were all highly respected and regarded Canadian rheumatologists.

The 2014 CRA Annual Great Debate was a rousing, heated, clever, entertaining, and educational event!

The Eastern Canadian team of Dr. Bykerk and Dr. Humphrey-Murto argued that we are doing too much monitoring of disease-modifying antirheumatic drugs (DMARDs) and biologics and too much screening before initiating biologic therapy with the presentation of five main points. Their first point was that demands on the Canadian healthcare system are high, yet resources are limited. A recent article¹ demonstrated a marked increase in the number of patients with rheumatoid arthritis (RA), yet no concomitant increase in the number of rheumatologists. The Choosing Wisely campaign (ABIM foundation)² has exploded as a direct result of the need to provide optimal yet efficient care. The team suggested that too much monitoring occurs, as evidenced by excessive monitoring for retinal toxicity of antimalarials³ and methotrexate (MTX) bloodwork monitoring exceeding guidelines in Canada.⁴ They also noted there is a lack of empirical evidence that monitoring changes outcomes. For example, increased liver enzymes occur in 50% of patients, yet are poorly predictive of histology and most enzyme elevations resolve without any dose adjustment.⁵ Monitoring needs to be tailored to the individual patient, they emphasized. Patients with no other risk factors for liver toxicity can safely be monitored less frequently while receiving MTX. Lastly, the “For” team added a little humour by suggesting that too much monitoring may be the result of greater problems such as obsessive compulsive disorder or fear of litigation. Rheumatologists were reassured that they rarely were sued.

The 2014 CRA Great Debate participants (left to right): Dr. Shahin Jamal, Dr. Vivian Bykerk,
Dr. Stephanie Keeling, and Dr. Susan Humphrey-Murto.

The Western Canadian team of Dr. Jamal and Dr. Keeling argued that we are not doing too much monitoring of DMARDs and biologics nor are we doing too much screening before initiating therapy. To begin, the team established that there is no good data regarding appropriate screening and monitoring of rheumatologic drug therapies. There are, however, clinical practice guidelines, including recently published CRA guidelines on the management of RA,⁶ based on available data and expert opinion that the team used as the basis of their argument. Survey results from practicing Canadian rheumatologists suggest most practice according to published guidelines. Consequences of insufficient monitoring include missing serious medication toxicity, the cost (both direct and indirect) of managing adverse events, and the risk of liability. Furthermore, rheumatologists do not have good data on appropriate monitoring of patients taking combinations of medications (rheumatologic and other). The team agreed with the Choosing Wisely campaign to provide optimal care but argued that, based on current available data, Canadian rheumatologists are doing the appropriate amount of monitoring. When using potentially toxic medications, the main goal is “do no harm.” Perhaps liability rates in rheumatology are low because we are doing appropriate monitoring and therefore preventing harm.

The 2014 Great Debate ended with the Western team suddenly and surprisingly leading a Flash Mob dance; many in the audience rose from their seats and took part! The Flash Mob performed to a song by the Village People called “Go West” that the team renamed as “Vote West!” The Chair of the Debate, Dr. Stephanie Ensworth, discovered afterwards that Dr. Jamal and Dr. Keeling contacted all of the ASM attendees from Western Canada prior to the meeting, involving them in a clandestine plan for this Flash Mob. It was a stunning effort accomplished on the part of these two Western Canadian debate participants.

In the end, by rounds of applause, the audience chose the instigators of the Flash Mob and the against team of Dr. Jamal and Dr. Keeling as the winner of the 2014 Great Debate, just edging out the “For” team of Dr. Bykerk and Dr. Humphrey-Murto. A superb time was had by all.

References

1. Widdifield J, Patterson M, Bernatsky S, et al. The Rising Burden of Rheumatoid Arthritis Surpasses Rheumatology Supply in Ontario. Can J Public Health 2013; 104(7):e450-5.

2. ABIM foundation. Choosing Wisely. Available at: www.chooseingwisely.org/

3. Browning DJ. Impact of the revised American academy of ophthalmology guidelines regarding hydroxychloroquine screening on actual practice. Am J Ophthal 2013; 155(3):418-28.

4. Bykerk VP, Schieir O, Akhavan P, et al. Emerging Issues in Pharmacological Management of RA: Results of a National Needs Assessment Survey Identifying Practice Variations for the Development of CRA Clinical Practice Recommendations. J Rheumatol 2012 ;39(8):1555-8.

5. Visser K, van der Heijde DM. Risk and management of liver toxicity during methotrexate treatment in rheumatoid and psoriatic arthritis: a systematic review of the literature. Clin Exp Rheumatol 2009; 27(6):1017-25.

6. CRA Treatment Recommendations for RA. 2012. Available at: www.rheum.ca/en/publications/cra_ra_guidelines

Stephanie Ensworth, MD, FRCPC
Clinical Associate Professor,
Division of Rheumatology,
University of British Columbia
Vancouver, British Columbia

on behalf of Vivian Bykerk, MD, FRCPC;
Susan Humphrey-Murto, MD, FRCPC, MEd;
Shahin Jamal, BScPT, MD, FRCPC, MSc; and
Stephanie Keeling, MD, MSc, FRCPC