Expanding drug armamentarium offers 'light at the end of the tunnel' for patients with RA
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The advent of biologics and other immunomodulatory options provides hope for patients with rheumatoid arthritis, according to a speaker at the 2021 Rheumatology Nurses Society annual conference.
J. Nicholas Manwaring, MSN, APRN, FNP-C, a nurse practitioner at the Alaska Native Medical Center, member of the Commissioned Corps of the United States Public Health Service, and a member of the board of directors for the Rheumatology Nurses Society, explained why swift and proper treatment of RA is so essential.
“The standardized mortality ratio is 2:1 in patients with RA versus the general population,” he said, adding that it can shorten a life span by 5 to 10 years.
The good news is that a growing therapeutic armamentarium and more specific guidelines for treating to target is offering options for clinicians and hope for patients.
While NSAIDs can provide short-term pain relief, they are “not ideal” because of long-term adverse events, including renal toxicity, according to Manwaring. “We try to use them for the shortest duration possible,” he said.
The immune modulator sulfasalazine has a rapid onset of action and strong anti-inflammatory effects, according to Manwaring. “It is good for patients who are suffering with severe synovitis, so it is a good thing to start with,” he said.
Sulfasalazine is also safe for pregnant women, although folic acid supplementation is recommended.
While an antimalarial drug like hydroxychloroquine does not have immune-suppressing qualities, its relative lack of toxicity makes it an attractive option in certain cases. “This is a nice drug because it doesn’t require as much drug monitoring,” Manwaring said. “However, you should notify patients to quit smoking, because smoking can reduce the effects.”
Methotrexate reduces active folate and adenosine and inhibits neutrophil function, according to Manwaring. “Methotrexate is now used as the standard DMARD which all others are measured against,” he said.
Methotrexate may be used as monotherapy or as a secondary agent. “It reduces the risk of antibody development with TNF inhibitors when used concurrently,” Manwaring said. “It has a fairly rapid onset of action.”
Dosing of methotrexate should typically start at 10 mg per week and gradually increase to 25 mg per week until “you get a maximum effect,” according to Manwaring. However, he suggested that dosing more than 20 mg per week may lead to adverse events without a substantial increase in therapeutic benefit.
Leflunomide is a good option for patients who cannot tolerate methotrexate, Manwaring noted. However, this drug should be avoided in patients with liver toxicity. “It also has a long-term half-life,” he said. “It can remain for up to 2 years in the system.”
Manwaring repeated the refrain about glucocorticoids that has reverberated through the rheumatology community in recent years, which is that long-term use is contraindicated. They can be used as short-term bridge therapy until another drug with fewer negative impacts on the immune system takes hold, but, otherwise, they should be used as sparingly as possible. “Try avoid longer than a month of steroids,” he said.
Turning to biologic therapies, Manwaring suggested that their potential impact should not be underestimated. “Biologics really revolutionized the treatment of rheumatoid arthritis,” he said, noting that cytokine-targeted drugs, TNF inhibitors, IL-1 and IL-6 inhibitors, along with JAK inhibitors all offer different mechanisms of action for RA patients.
While much has been made of skin malignancy risk associated with biologic therapies, the risks are “kind of fuzzy in the research,” according to Manwaring. “As RA is also associated with increased malignancies, it is hard to tell if it is the drug or the RA.”
To be safe, yearly skin screenings are “probably a good idea,” Manwaring added.
Looking ahead, Manwaring suggested that increasing use of biosimilar therapies in Europe is likely to make its way west to the U.S. for one important reason. “The big advantage is price,” he said.
In closing, Manwaring is optimistic that patients with RA will benefit from all of the treatment options available and, possibly, improve upon early mortality statistics. “There is light at the end of the tunnel,” he said.
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Manwaring JN. Latest Treatments and Guidelines on Rheumatoid Arthritis (RA) for the Nurse and Advanced Practice Provider (APP). Presented at: Rheumatology Nurses Society annual conference; August 4-7, 2021 (virtual meeting).
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