Clinical Pearls for RA Management

Nehad Soloman, MD: I think we've gone through a litany of different ideas about the drugs and how we use them. One of the concerns that many people have when anything new comes out is, is it reliable? I know, certainly, when drugs come out, is it effective, is it safe, and then can my patients get it? We ask the same questions with laboratory tests. Is it effective? Is it reliable? Can my patients get it for free or covered through insurance? With that, I think I'd like to get the last part. I'm going to hear from both of you. What advice do you have for your colleagues treating rheumatoid arthritis in the community setting? Joy?

Joy Schechtman, DO: I think we've come a long way. I think rheumatologists need to commend themselves. First of all, rheumatologists are still the subspecialty that still listens to patients. We still examine our patients. We use all of our clinical tools, we don't rely just on testing alone. However, we are probably the group of subspecialists that question and ask those questions on how this test is going to benefit our patients. And so I think that we do look at science, and the fact that we are getting these studies that are showing us consistently that looking at the signaling and whether a patient is going to have a response or not have a response to certain medications, and as we get into more precision medicine, and we see that these tools are going to help us to get our patients into low disease activity quicker and get to that treat to target quicker, I think we're going to rely on them more. Like Bob has said, it's going to take us a few years. There's going to be our early adopters that are going to look at this and look at that science and study it and say, ‘This is a tool in my toolbox, I’m going to use it with my clinical exam. I’m going to use it with all my laboratory testing, and I’m going to move into that direction quicker, and I’m going to see the response probably in my patients a little bit quicker.’ Then there are going to be the early adopters. There are going to be our colleagues that are going to take a little bit more time. But I think over the next few years you're going to see a big change in how we approach our patients. We're going to be commended for how quickly we take care of the patient journey and get these patients in low disease activity, and maybe at some point, rheumatoid arthritis will not have the stigma that it has had over the last several years, at least in my career, that this is a "crippling" disease process. Thank you.

Nehad Soloman, MD: Bob?

Robert Levin, MD: Joy said it very nicely, and I would like to add that this technology has great potential. We're only scratching the surface based on the data on looking at the signal of nonresponse to TNFs [tumor necrosis factor], and hopefully getting more patients involved and more data collected will strengthen the argument that this is a reliable piece of information that will really help us guide therapy. Second, I look forward to the day that the adoption by CMS [Centers for Medicare & Medicaid Services] and adoption by the commercial insurance carriers will help us guide therapy and allow us to have this be an affordable option for us to use and not have the worry of large out-of-pocket expenses and concerns about that. Then, I just think that this really has the opportunity to help guide our patients to get to those treat to target goals, low disease activity, remission. That would ultimately lead to getting our patients to our goals as providers, as doctors, and also to the patient goals of improving those quality-of-life and patient-reported outcome things that we measure.

Nehad Soloman, MD: I think both of you hit the nail right on the head. We need more tools. We need more information. We need more accessibility to these tools because although we've had a tremendous explosion of therapeutic options, we haven't had any real guidance. To have a test that may guide our hand in therapy, even for just the first decision or even beyond that, because as we both and all know here, the therapy selection right now comes down to what are we most comfortable with? What came first? Maybe comorbid conditions, but mainly insurance mandates. Use this, then that, then this because that's our formulary. That's our sequence. I think many of us are feeling choked by this because as scientists, as rheumatologists, we are data-driven. We know better, and we know that as this science evolves in the 21st century, precision medicine is the way we can learn from our oncology colleagues. With that, I'd like to give a thanks to all of you for this rich and informative discussion. Before we conclude, I'd like to get final thoughts from each of you. Joy?

Joy Schechtman, DO: I wholeheartedly agree with everything that has been said here today. We're in a very rich environment that we have a lot of potential, a lot of hope, down the line by having a good collaboration with the science, with the testing, to give our patients that precision medicine that we want to achieve and to get these patients into the remittive state that they should be able to get into. By using good science and showing insurance companies that we are scientists, that we use evidence-based medicine to make some of our decisions. I hope through the work of the CRSO [Clinical Research Support Office], Bob, and my other colleagues, and I know myself I've tried to work in that area as well, that we'll be able to convince our insurance payers that this is the way to go for our patients and to get them into low disease activity in remission as quickly as possible.

Nehad Soloman, MD: Bob, what are your final thoughts?

Robert Levin, MD: I'm going to throw one out there. I'll put on my advocacy hat for a minute and just say that we've been really trying to improve formulary construction based on efficacy and safety. That flies in the face of the payers and the PBMs [pharmacy benefit managers] who basically construct formularies based on what's most profitable to them and not at all what's related to safety or effectiveness. I see this being a real tool that we can use from the advocacy standpoint in fighting the PBMs, in other words, being a PBM buster. That it could blow up their whole paradigm. I'm doubly excited, not only based on the science and how patient outcomes can be affected by utilizing this, but also utilizing it as maybe a cajole against the payers and against the PBMs who are unfortunately in control of what we prescribe and getting in the way of the doctor-patient relationship.

Nehad Soloman, MD: Well, Bob and Joy, thanks to you and our audience for this rich and informative discussion. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchanges and other great content right in your inbox.

Transcript edited for clarity