Plenty of rheum to improve

President of the Irish Society for Rheumatology (ISR) Dr Sinéad Harney spoke to Catherine Reilly ahead of the Society’s Spring Meeting and outlined some pivotal issues affecting the specialty

Members of the Irish Society for Rheumatology (ISR) gathered recently in Dublin for its Spring Meeting, which is a key event in the Society’s calendar. The meeting on 12 April was organised by Consultant Rheumatologist Prof Geraldine McCarthy and colleagues at the Mater Misericordiae University Hospital, Dublin.

Speaking to the Medical Independent (MI) ahead of the event, ISR President Dr Sinéad Harney said the agenda was probably the best that the Society has had in years.

One of the most anticipated talks was on pregnancy in rheumatology patients, which was delivered by Prof Catherine Nelson Piercy, Consultant Obstetric Physician, Guy’s and St Thomas’ Foundation Trust and Imperial College Healthcare Trust, London, UK. “A lot of our patients are women of child-bearing age,” noted Dr Harney, a Consultant Rheumatologist at Cork University Hospital (CUH).

Dr Harney would see one-to-two pregnant women at every clinic. She said the subject of the talk was “very relevant”, as there were now drugs that could be used throughout pregnancy.

Another topical presentation, by Prof Gary MacFarlane, Clinical Chair in Epidemiology, Dean of Research and Knowledge Exchange (Life Sciences and Medicine), University of Aberdeen, UK, examined why people with chronic pain die prematurely.

“Chronic pain is really common and we are poor at treating it, and there are a lot of comorbidities,” remarked Dr Harney.

The ISR President also highlighted the presentation by Dublin inner-city GP Dr Austin O’Carroll on ‘Managing Health in Time of Chaos’ as something different and informative for delegates.

Biosimilars

While not on the official agenda, Dr Harney predicted that the issue of biosimilars would be a talking point among rheumatologists attending the meeting.

“That is on everybody’s mind, but the HSE haven’t engaged with us at all over it. I don’t know what has been happening centrally and what has been happening with industry, but they certainly haven’t talked to any rheumatologists about it. So that may not be discussed formally at the meeting, but I imagine it will be discussed informally.”

Dr Harney said use of biosimilars had been implemented on a small scale at CUH, where a group on the subject was chaired by Consultant Rheumatologist Dr Gráinne Murphy.

Around half a million euro was saved last year through use of biosimilars and the hope was that some of this funding will be provided to the rheumatology department.

The ISR President noted recent media reports that the HSE had spent over €1.2 billion on biologics since 2016, and only €2.2 million on biosimilars in the same period.

“And biosimilar companies have threatened not to come into this country because of it. Our uptake of biosimilars has been poor, to be honest. What they did in the UK was, they made it a rule and they brought in nurses to explain what they were doing, but we asked for directions from the Department of Health and the Minister for Health and we got nothing… I have used biosimilars, but in a very small capacity. I think that will definitely change over the next five years.”

Clinicians would like to maintain a degree of autonomy in this area, she confirmed.

“There will always be certain scenarios where you can’t choose one or the other. The most obvious place is pregnancy, but that is a small niche group. We’d still like a bit of freedom. But when you look at the figures in the paper, there is a whole lot of money to be saved.

“I have put new patients on biosimilars; I think it is hard to switch patients who are doing well. I think the UK have done it really successfully, but what they have is a fleet of nurses explaining to patients what is happening. In the next 10 years, I suspect I will be more limited in what I can prescribe. I don’t necessarily think that is a bad thing, because we have so much choice at the moment.”

Between Dr Harney and two other rheumatologists at CUH, there is a patient cohort of around 3,000 on biologics. Therefore, IT and nursing support would be required to assist rheumatologists nationally in switching their patients to biosimilar medications, she emphasised.

General medicine commitment

The ISR President believes the pivotal issue facing rheumatologists in Ireland is their commitment to general internal medicine. According to Dr Harney, this is significantly contributing to long rheumatology waiting lists.

“We have a 28-month waiting list in Cork and that is probably one of the worst in the country. But there have been two ways the rheumatology community has gone in the last few years. Smaller hospitals, in Galway, Navan, Limerick, Waterford, Sligo… just do single specialty rheumatology and have appropriate waiting lists of three months [for outpatients].”

However, in the bigger hospitals, rheumatologists also have a commitment to general internal medicine. Dr Harney said that, in Cork, the outpatient waiting list for rheumatology is 28 months for routine appointments and 11 months for urgent appointments.

“So whether rheumatologists should be doing general medicine at all is where we are angling. Cork and Dublin and the biggest hospitals are all doing general medicine, which really limits our ability to do our specialty. It is a big, big issue.

“General medicine is consuming our time to do rheumatology. To me, that is our biggest issue at the moment — the negative impact of general medicine [workload]. I don’t dislike it, it is just taking up too much time.”

She added that rheumatology was under-served in Kerry, “so we have probably the worst ratio of rheumatologists to population in the country down this end of the country”.

There was still no dedicated space for rheumatology at CUH, according to Dr Harney, a matter she raised in an interview with MI ahead of last year’s ISR Spring Meeting.

The rheumatology department has access to a day ward with six beds for one-and-a-half days a week and “a few” inpatient beds. “We don’t have a rheumatology space dedicated in CUH where you could do a lot of things [efficiently]; other hospitals are better than our hospital; there are better places.”

Last year, Dr Harney also reported that lack of capacity at CUH meant that patients requiring six-monthly infusions were being pushed out to nine months. She said this issue “has gotten worse” and referred to patients being seen at 10-month intervals.

Where possible, Dr Harney had referred patients to the private sector when they have private health insurance.

“The public patients are not getting seen in a timely manner and that has not improved or changed… we have been upset about it for a year now and they [hospital] have done absolutely nothing.”

Recruitment remains a live issue for the specialty. It was “crying out for more consultants”, a matter repeatedly highlighted for many years, according to Dr Harney.

She reiterated that “the ideal” would be for single specialty rheumatology to prevail. “It is the only way we are going to tackle our waiting lists.”

On a more positive note, Dr Harney said access to drugs including new Janus kinase (JAK) inhibitors was positive for the specialty. Moreover, Dr Harney acknowledged some good news on the recruitment front, with appointments of an extra rheumatologist in Galway University Hospital and a replacement post at St Vincent’s University Hospital, Dublin.

Meanwhile, Dr Harney revealed that she will be participating in the Dublin Women’s Mini Marathon on 2 June alongside the CEO of Arthritis Ireland Ms Gráinne O’Leary.

“We are doing the Dublin Women’s Mini Marathon in June to raise awareness about women with arthritis, and why people with arthritis should do exercise and the absolute importance of exercise. That is a positive thing we are doing. There has never been a female president of the ISR at the same time as a female head of Arthritis Ireland, so we are pushing that. We will all be wearing orange and we are trying to get as many female consultants in the country [involved].”

A YouTube video has been created to publicise the initiative (https://www.youtube.com/watch?v=sacmq3YIPIc).

The aim is to promote activity and exercise in arthritis and emphasise that “exercise is good for you; it is good medicine, and if there are 10 or 15 of us running the Dublin mini marathon we might get seen, it might get picked up,”  Dr Harney outlined. “That is a joint initiative between the ISR and Arthritis Ireland.”