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25% Reduction in Rheumatoid Arthritis bDMARD Cost Possible With Avatar Assistance

A rheumatoid arthritis—focused Virtual Health Assistant (aka avatar) could help save US health plans over $1 billion per year by providing the data needed to pursue an evidence-based dose reduction/discontinuation strategy for biologic DMARDs (bDMARDs). The science is strong, but is the will equally strong?
 
Infliximab
RRR Study: “71.4% of patients with deep remission were able to continue Low Disease Activity (LDA) for one year” after stopping infliximab. 
 
BeSt Study: 56% of patients reaching LDA for 6 months while taking infliximab were able to discontinue infliximab and maintain LDA for 1 year. The findings went on to state that “more than half of patients who discontinued infliximab successfully maintained LDA for more than 8 years.”
 
Adalimumab
HONOR Study: “approximately 80% of patients with deep remission were able to sustain low disease activity for one year without adalimumab.” 
 
OPTIMA Study: LDA and remission was maintained in “66% of patients who withdrew from adalimumab treatment.”
 
HARD HIT Study: 44% of “patients were still in remission by 24 weeks” after stopping adalimumab.
 
Etanercept
PRIZE Study: Methotrexate (MTX)-naïve, early RA patients who were initially treated with MTX and etanercept achieved disease activity remission in 70% of patients. The patients were then randomized to a double-blind, 39-week trial of either:
1. Reduced etanercept plus MTX
2. MTX with placebo
3. Double placebo.
 
Sustained remission was seen in 63.5 % of those who maintained reduced etanercept plus MTX, 38.5% of those maintained on MTX plus placebo and 23.1% of those maintained on double placebo. The authors went on to state, “There was no significant radiographic progression in any treatment group.”
 
EMPIRE Study: 110 DMARD naïve patients with early inflammatory arthritis were randomized to receive MTX plus etanercept or MTX plus placebo. After either reaching “no swollen or tender joints” or reaching 52 weeks, all injections were stopped. In those who had initially been treated with etanercept plus MTX, 57.7% remained in remission and LDA after ceasing etanercept for the next 26 weeks. 
 
Tocilizumab (TCZ)
ACT-RAY Study: 556 patients with established RA with mean duration of over 8 years who inadequately responded to MTX were randomized to receive either 8mg/kg TCZ plus MTX or 8mg/kg of TCZ plus placebo. After ceasing therapy, 14% did not flare.
 
DREAM Study: In 187 patients who showed LDA on TCZ (for varying periods of time) and then were discontinued: 13.4 % remained LDA after discontinuing TCZ and 9.1% remained in drug-free remission at 52 weeks.  According to the authors, most responded promptly to restart of TCZ.
 
Cessation or Dose Reduction Strategy Is Effective
Overall this review article stated: Taken together, these recent studies indicate that “30-79% of early RA patients could discontinue bDMARDs without clinical flare and functional impairment after reduction of disease activity…”
 
But, Dose Reduction Strategy Requires Good Data
The authors made a point that close monitoring is essential. Basically disease activity must be measured on a regular basis both prior to and after initiating a dose reduction strategy. First to see who might be a candidate for dose reduction or cessation and then to measure response to dose reduction to provide data on who needs to be restarted on their bDMARD.
 
It would be virtually unheard of for this to occur in the US, as US physicians do not actually measure disease activity on a regular basis. In fact, none of the studies in this systematic review article were performed in the US. This author speculates that it is because we lack data, something that is actually rather easy to collect—if we have a virtual health assistant acting as the collection agent.
 
An article on the Arthritis Foundation website discusses how rheumatologist Nathan Wei, MD, occasionally uses the DAS28 in his practice. “Some days I’m a DAS user, some days I’m not.” He said he spends more time asking patients, "How are you doing?"
 
The article went on to say he would then “consider what the patient says about his or her condition, the results of lab tests, and an occasional imaging exam (usually an MRI) to make treatment decisions.”
 


 
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