Case-Based Approach for the Management of Rheumatic Diseases - Episode 9
Transcript: Madelaine A. Feldman, MD: There have been studies regarding what to do if a patient does not respond to a TNF [tumor necrosis factor] inhibitor. That is your first choice. And you have methotrexate on board. There really is a difference in whether they stop the medicine because they’re having an adverse effect versus having a loss of effect. If the patient never really got a good effect from the TNF inhibitor, your chance of getting a better outcome with another TNF is about 40%. Because we have so many mechanisms of actions that we can use now, we’re finding that rheumatologists are moving to a different mechanism of action. I still think TNF inhibitors tend to be the first choice. They’ve been around the longest. It depends on the patient’s age, their other comorbidities, and whether they’ve had infections. Is it easy for them to come get an infusion? Do they have a problem with giving themselves a shot? Would they rather take a pill? All these things have to come into consideration when we’re trying to figure out the best medication for a patient.
But I think we’re seeing now that if a TNF fails the first time around, we have so many other choices and so many other mechanisms of action. Unless you’re switching the formulation, perhaps you might go from a self-injectable to an infusion with a TNF. Or, because there may be an adherence problem. Those are all the kinds of things that you have to take into consideration when you’re making that choice of what to start the patient with and what to possibly switch them to, regarding another medication.
Transcript Edited for Clarity