Earlier switching, aggressive treatment approaches may be best for RA
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Although there is a wide array of therapies for patients with rheumatoid arthritis, the choice of when and how aggressively to employ them can sometimes conflict with established guidelines, according to a presenter.
“Rheumatoid arthritis guidelines are problematic,” John J. Cush, MD, director of clinical rheumatology at the Baylor Research Institute in Dallas, Texas, told attendees at the 2020 Rheumatology Nurses Society Annual Conference. “Most of the guidelines for what we do are not based on good clinical trial data.”
In fact, most recommendations for arthritis treatment are grade C, which Cush noted is based on “expert opinion,” lending them subjectivity.
With this in mind, Cush offered some strong opinions about how the treatment of RA should be approached. His first point was that there are nine biologics, 13 biosimilars and six oral conventional DMARDs approved and available for use. “You have a lot of choices,” he said. “How are you going to use them?”
Cush answered this question in a few ways. His first suggestion was that rheumatologists often do not switch therapies soon enough in patients who fail to show a response. “How long do you wait [for a response]?” he said. “People say 12 weeks, but a lot of data show that people switch at 48 or even 100 weeks.”
If, at the first follow-up visit at week 6, the treatment is not working, clinicians should already be thinking about switching, according to Cush. “If it is working, it should start working right away,” he said.
The next consideration is whether to cycle through multiple TNF inhibitors or move to another mechanism of action. The answer is a “no brainer,” according to Cush. “There is a paucity of trials that prove TNF switching works,” he said. “Other drugs work as well.”
When it comes to choosing that next therapy, Cush believes JAK inhibitors should be seriously considered over methotrexate. “The bottom line is, JAK inhibitors are better than methotrexate,” he said. “They have a faster time to response.”
That said, Cush believes that methotrexate can work in about one-third of patients “right out of the gate,” provided it is used aggressively. “Use 15 mg or 20 mg of methotrexate right from the start,” he said. “If there is no response, keep methotrexate and add on.”
The final approach Cush suggested pertains to triple DMARD therapy. “Most of you do not use a triple DMARD approach, but there is really good evidence that [it] works,” he said.
For patients with disease that has proven difficult to control, it is a good idea to “hit control-alt-delete and reboot the system,” according to Cush.
“Delete the drugs they will not take,” he said. “Whatever the reason is, take it off the list.”
The next step is to delete all drugs that they have failed previously. “If they failed, you probably don’t want to use that class of drugs going forward,” Cush said.
At that point, it may be useful to simply ask the patient what they believe controlled their disease best. If the patient is unsure, Cush suggested trying half a dose of a new medication, and adding alternative agents, whether it is a JAK inhibitor, mycophenolate mofetil, leflunomide or tacrolimus. “When you are stuck, try something else,” he said.
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Cush JJ. Current Treatment Guidelines and Trends on Rheumatoid Arthritis (RA). Presented at: Rheumatology Nurses Society annual conference; August 5-8, 2020 (virtual meeting).
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