Trial-and-Error Approach to RA Treatment

Nehad Soloman, MD: As we’ve had advances in medicines, we’ve also had updates. The American College of Rheumatology and the European League Against Rheumatism in the past decade, as we’ve had advances in treatment, have updated their guidelines. Can you tell us a little about how that’s impacted your decision-making?

Robert Levine, MD: It’s an important issue. When I was starting out, we had the pyramid. You started with what they considered the safest drugs, NSAIDs [nonsteroidal anti-inflammatory drugs], which it turns out aren’t the safest drugs. We moved on, only when they were through all different modalities, to a traditional DMARD [disease-modifying antirheumatic drug], such as gold salts or methotrexate. That process took years. We discovered, as Joy mentioned during her response to the last question, that the clock is ticking. We don’t have forever to get the patient on the right therapy. Especially in patients with more aggressive RA [rheumatoid arthritis], if they don’t start on that medicine and we don’t get them on the right therapy and down to low disease activity remission, the ongoing accrual of joint damage and other complications—the increased cardiovascular risks, the comorbidities—are much worse.

This comes from our guidelines: we want to move through therapies that are required based on the third parties. If that works, great. It works for a minority of patients to give them methotrexate. But for the others—and that’s the majority—we need to get them onto the advanced therapy so we can get to our treatment goals. By the way, treatment goals are a mutual decision; it’s shared decision-making. The patient’s treatment goals may be very different from what I’m think as my treatment goal, which is to get them into low-disease activity or remission if possible.

Nehad Soloman, MD: That’s exactly right. A lot of my patients share a vision of treatment goals, but their vision is more, “I want to feel better. I don’t want to feel as much fatigue. I want to have better sleep.” Whereas we’re driven to count the joints and see how many tender and swollen areas there are. As we’ve had this explosion of biologics and targeted synthetic therapies in the last 2 decades, it’s led to a bit of a debacle. Which do you choose first? Often times, we have this trial-and-error approach. Joy, how have you found that in the last couple of decades?

Joy Schechtman, DO: Bob had a lot of good points. He’s talking about this shared goal with the patient. We have to include the patient in any decisions we make. When we’re thinking about what could potentially happen to those patients, we want to explain to them that we’re trying to prevent further damage with their joints and heart and long-term problems that could occur from this disease. Yes, we want to give them hope because we have great medications. That shared decision-making is very important in how we proceed. The patient has different goals from what we physicians sometimes have. [We need to] sit down from the beginning and say, “What are your goals? What do you want to achieve?”

If I have a patient who is on an oral medication and seems to be doing well, or they think they’re doing well but I don’t, then that’s where some of the issues come in. I have to explain to them what I’m seeing on clinical exam. The patient’s goals and the physician’s goals are sometimes different. You have to say, “I’m still seeing active swelling, an activity of disease.” We want to move in a different direction and maybe use mediations that will act more targeted and act on the inflammatory process.

Then you have to give them options according to what their lifestyle is. Maybe you’re going to go to a biologic given by injection. Maybe that biologic is given by IV [intravenous]. I try to take that next step to see where their aversions are, what they’re scared about. Some patients say, “I can never give myself an injection.” I say, “We have an IV option, and we can talk to you about that.” We may go into the IV types of medications the biologics in that regard.

If that patient says, “I want to stay with the oral medication,” then we may go to a targeted synthetic. However, the guidelines have recently changed. When we’re dealing with some of our treatment goals, I call it a triangle: we have to look at the disease, what the right treatment is, and the insurance. With the insurance part of it, sometimes I have to go to a TNF [tumor necrosis factor] treatment, a biologic treatment. That’s when I say, “We have to go to a TNF drug. Would you like to do injection or IV?” I use graphs to explain to them how that’s going to work on that inflammatory cycle.

The key point is getting that patient’s end point and talking to them about what they’re goals are. Maybe they’ve given up certain activities that we can get back for them. I also explain to them about this window of opportunity in the first few months of getting control of the patient. I agree with what Bob said. We have to think about going very quickly with these patients because of the risk of permanent damage. That’s key as well. As rheumatologists, we understand that better than the patient.

Transcript edited for clarity