Difficult-to-treat RA calls for reassessments of medication, diagnosis
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Physicians should confront difficult-to-treat rheumatoid arthritis by rethinking the diagnosis, reassessing available medications, and — importantly — talking with the patient, according to a speaker at the 2020 Congress of Clinical Rheumatology-West.
A EULAR recommendation, published Sept. 30, provided the following three criteria for difficult-to-treat RA:
- treatment according to EULAR recommendation and failure of at least two biological or targeted synthetic disease-modifying antirheumatic drugs (DMARDs), with different mechanisms of action, after failing conventional synthetic DMARD therapy, unless contraindicated;
- the presence of at least one of the following: moderate disease activity; signs or symptoms suggestive of active disease; the inability to taper glucocorticoid treatment; rapid radiographic progression; or reduced quality of life due to RA symptoms; and
- the management of signs or symptoms is viewed as problematic by the rheumatologist and/or patient.
“I think all of us, when we see patients, have different definitions of refractory,” Arthur Kavanaugh, MD, of the University of California, San Diego, told attendees at the virtual meeting. “One of the things where I’m not sure how I feel about it, is that refractory is excused if access is limited due to limited socioeconomic factors, but I think that is an important consideration.”
“Also, patient preference, I think, is something that I’m not sure where it fits in all of this,” he added. “It goes back to the treat-to-target argument, where we are doing something to patients to get them better, but I think of course in real life we always do it with the patients, with their input.”
To address difficult RA, Kavanaugh recommended heeding the advice of colleague Jack Cush, MD, of Baylor University Medical Center at Dallas, who developed the following “checklist”:
- Rethink the diagnosis, particularly if the “rheumatoid arthritis” you are treating fails to respond to your best medications.
- Pain caused by damage or central sensitization may require a team approach.
- Make the best use of medications, including methotrexate, and ensure compliance.
- Do not be ‘handcuffed’ by safety limitations.
- Avoid polypharmacy and make wise choices regarding deselection.
- Address exogenous factors, included sleep, depression, diet, exercise, smoking and socioeconomic factors.
- Talk to your patient.
“Make sure the diagnosis is correct and think about the pain that is noninflammatory,” Kavanaugh said. “Are we using our medications in the best way? Have we thought about the different treatment options? Jack would say, ‘Don’t be afraid of the safety,’ and of course that is an extended discussion with the patient.”
“Also, particularly in the time of COVID-19, think about the people who are kept prisoner in their own houses and unable to move,” he added. “They may be safe from COVID-19, but it could be wreaking havoc on their overall mental status and potentially on their (RA).”
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Kavanaugh A. Rheumatoid arthritis: Recent concepts. Presented at: Congress of Clinical Rheumatology-West annual symposium; October 8-11, 2020 (virtual meeting).
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