ACR/EULAR Recommendations for Switching Therapies in RA

Nehad Soloman, MD: What are your thoughts on the ACR [American College of Radiology] and new lower guidelines with regards to waiting 3 months before you consent or consider a change in 6 months to give it an optimal time to reach a target? This could be either one of you.

Robert Levine, MD: I’ll start with that one. I agree with it. I would say the caveat is, if there’s nothing, they have 0 response at 6 weeks, I think that that’s almost destined to fail. If they have a partial response at 6 weeks or 3 months, I’m willing to give it longer to see if we get a more complete response, but that’s really how I see that.

Nehad Soloman, MD: Is it a CDAI [Clinical Disease Activity Index] low disease, no disease? What are the targets that you’re looking for to get that response?

Robert Levine, MD: For me it’s a CDAI of low disease activity or what’s considered remission, so CDAI less than 10 is the number that I’m looking for. If the patient started with massive disease activity, meaning every joint was swollen and tender and they were totally incapacitated when you started it, it’s awfully hard to get the patient down to that. There is a little bit of gestalt and a little bit of consideration of we got the patient just above low disease activity, but they started with a CDAI of 50 and is that acceptable? There is some individualization of it, and, in my opinion, we should not be dogmatic about it, but I think in clinical trials and protocol, there is some dogma to it, but there is some individualization of it.

Nehad Soloman, MD: Agreed, Joy?

Joy Schechtman, DO: What I explain to the patient is, treat to target. Get that patient to low disease activity. We don’t use a lot of the times the terminology “remission,” but I want to get them as good as I can get them as quickly as I can get them into that stage. I tell them that I’m not going to stop changing medication until I get them to that treat to target level. That’s important to prevent further ongoing comorbidities and destruction of their joints. There’s, a lot of times, a disconnect between what the physician wants and what the patient wants, and I explain that to them. The patient wants pain relief; the physician wants decreased inflammatory changes. I’m looking at the inflammatory process and by getting their inflammation down, their pain should follow that and should decrease, as well. If the patient doesn’t understand that, all they think I’m treating is pain relief, so I think that’s also important to explain to the patient about the differences in what our targets are. I definitely take a treat-to-target type of approach, and I tell that patient in 3 months, if they’re not getting the effect, we’re going to start looking and discussing other options for them. I agree with what Bob is saying. My Medicare patient, I feel a lot more liberty as to what I can pick from and I can choose and be a little bit more complex and get the combination where I want it to be. When I’m dealing with that commercial patient, I have to look at the plan and what the requirements are. I agree the science is not necessarily there. The insurance company is the middleman in between the physician; we have the insurance, and we have the patient, and they are not always looking on behalf of that patient, what is the best drug for that patient. The clinician who understands that patient, understands the science and understands where that patient is, as far as high disease and where you’re trying to get them on that treat-to-target journey, is the best one to make that decision, and sometimes our hands are tied in getting that patient to where we think we need to get them to. It’s unfortunate.

Robert Levine, MD: Joy, I think what you’re talking about is such an important issue and that really is the sanctity of the doctor-patient relationship.

Joy Schechtman, DO: Absolutely.

Robert Levine, MD: There is no way that we should have this third party that’s coming down on us and coming down on our patients, that is intervening and telling us what to do and how to manage our patient “better.” They don’t know “better” and really, I don’t know how or why we let them get in that position, but it’s a fact. The sanctity of the doctor-patient relationship and the treatment decisions that go on in that relationship are so critically important. From an advocacy standpoint, I have to say that that’s something that we need to advocate for very strongly.

Transcript edited for clarity