A pair of leading academic rheumatologists who took part in a live discussion with A. Mark Fendrick, MD, co-editor-in-chief of The American Journal of Managed Care, agreed that an accurate early diagnosis of rheumatoid arthritis (RA) is the key to getting the patient started on disease-modifying therapy. The goal today is achieving remission of the disease, not just managing its symptoms, according to Eric Ruderman, MD, professor of medicine, rheumatology, the Feinberg School of Medicine at Northwestern University; and James O’Dell, MD, professor of internal medicine, division of rheumatology, University of Nebraska College of Medicine.
The concept of “treating to target” now governs care in RA, O’Dell said, and the target for most patients should be remission, or lack of persistent disease activity. While O’Dell and Ruderman agreed that it can be challenging to quantify levels of disease activity, rheumatologists are developing composite measures to properly assess patients.
“The significant majority of patients should be at or near complete remission,” O’Dell said. Diagnosis can and should occur much earlier, he added, as rheumatologists have gained awareness of the importance of putting patients on disease-modifying antirheumatic drugs (DMARDs) as soon as possible.
Rheumatologists work to stay close to primary care physicians (PCPs) or orthopedists, who may be the first to hear patients’ complaints about morning stiffness or inflamed joints, Ruderman said. Today, a blood test, the anti-cyclic citrullinated peptide (anti-CCP) antibody test, is used to evaluate patients. While rheumatologists have full calendars, Ruderman believes that if a patient’s symptoms and antibody test suggest the possibility of RA, most will find a way to schedule the patient. “We want to get the patients before there’s damage that’s permanent,” he said.
The participants agreed that RA patients need to be treated by a rheumatologist, but that the PCP plays a critical role in managing comorbidities such as cardiovascular disease. And while the anti-CCP antibody test is useful, some PCPs err by being too reliant on a test or imaging to make a diagnosis. PCPs shouldn’t hesitate, when presented with a negative test result, to make referrals in borderline cases, Ruderman said.
O’Dell said RA treatment has changed, in part, because of a shift in attitude. Decades ago, many doctors assumed there was not much that could be done for arthritis patients, and some paid little attention to distinguishing between RA, an inflammatory disease that affects the whole body, and osteoarthritis, a degenerative condition of the joints. RA that afflicts younger patients is of special concern because of what can occur if the disease is not controlled—RA patients are at higher risk for heart attacks and strokes.
Changes in diagnostic criteria have come with the new outlook, Ruderman said. Old criteria included progression to joint damage in the diagnosis, but that has been removed. “It didn’t make sense to wait for that” to diagnose RA, he said.
Start With Methotrexate
Methotrexate is the “foundation” for RA treatment, O’Dell said. Only a small number of patients, such as women planning to become pregnant, should not start this therapy once RA is diagnosed. Ruderman said if the disease is not controlled after 3 to 4 months, another drug can be added, but that does not mean methotrexate should be discontinued. Most studies of other drugs, he said, including some of the biologics, show that therapies typically work better in combination with methotrexate.
Rheumatologists are comfortable with methotrexate in part, Ruderman said, because it has been around for many years and clinicians know more about its long-term toxicity than they once did. It turns out the drug is not as toxic as was once feared, and dosing can ramp up more quickly than doctors formerly believed.
Patience is needed, O’Dell explained, because methotrexate can take up to 6 months to render its full effect. A critical error some rheumatologists make is moving on to a different drug before methotrexate has had time to work.
“Clinicians escalate methotrexate at different rates; even now, people escalate too slowly,” O’Dell said. One reason for this is that it’s difficult to get in to see a rheumatologist; thus, increased dosing often does not occur for 2 to 3 months.
Lifestyle modifications, especially quitting smoking, are important, but they do not replace disease-modifying therapy, the rheumatologists agreed.
Interruptions of Coverage Can Harm
The final part of the discussion involved issues of insurance coverage for therapies. Both rheumatologists told Fendrick that issues of cost and coverage come up almost every day they spend in the clinic. Ruderman said it’s especially frustrating to see some patients go without their medication for a month at the beginning of each calendar year while dealing with prior authorization issues. “It just can’t be good for care,” he said.
Fendrick said that under healthcare reform, the goal of “value-based” medicine is to eliminate these kinds of hurdles for doctors and patients who have already demonstrated the need for and effectiveness of a therapy. Repeat prior authorizations, he maintained, should not be demanded just because a drug is expensive.
Editor’s Note: To hear the full discussion, visit http://bit.ly/1nxPuyO.