Advances in Targeted Therapy Selection in Rheumatoid Arthritis - Episode 1
Drs Nehad Soloman, Joy Schechtman, and Robert Levine describe the treatment path from conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) to biologic or targeted disease-modifying antirheumatic drugs (b/tsDMARDs) for a typical rheumatoid arthritis (RA) patient.
Nehad Soloman, MD: Hello, and welcome to this HCPLive® and Rheumatology Network™ Peer Exchange titled “Advances in Targeted Therapy Selection in Rheumatoid Arthritis.”I’m Dr Nehad Soloman. I’m a rheumatologist at Arizona Arthritis & Rheumatology Associates in Phoenix, Arizona. Joining me in this discussion are 2 of my colleagues. Dr Joy Schechtman is a rheumatology specialist at Sun Valley Arthritis Center in Peoria, Arizona, and a clinical professor of medicine at Midwestern University in Glendale, Arizona. Also joining me is Dr Robert Levine, a rheumatologist in Clearwater, Florida, who is on the board of directors of American Arthritis & Rheumatology Associates…. Joy, tell us a little about yourself and your practice.
Joy Schechtman, DO: Thank you, Nehad. I’ve been a practicing rheumatologist since 1985. I see many patients with multiple diseases in my practice. We’re very active in teaching. We have residents from internal medicine and also family practice in our office learning. We also have a physician assistant and third- and fourth-year medical students from the medical school. We do a lot of clinical research. I’ve been involved in approximately 200 clinical trials. We’re very active as far as doing infusions in our office and involved in osteoporosis at a very high level.
Nehad Soloman, MD: Thanks, Joy. Bob, tell us a little about yourself and your practice.
Robert Levine, MD: Thank you, Nehad. I’ve been in practice in Clearwater, Florida, since 1989. As part of my practice has also been involved in clinical research. I’ve been a research principal investigator since 1990. I haven’t counted how many trials I’ve been involved with in rheumatology, going all the way from phase 1 to 4. I also train fellows as part of a program affiliated with University of South Florida. They rotate through my office and get good training there and through the academics involved in the program.
I’m also involved with advocacy on behalf of rheumatology. I’m on the board of directors of the Coalition of State Rheumatology Organizations, CSRO. We’re trying to promote access to care for our patients. I have other organizations. I’ve been the past president of the Florida Society of Rheumatology, and I’m the [resident of another patient-provider access organization called the Alliance for Transparent & Affordable Prescriptions, which is working to improve access to care by educating and advocating against the regime of pharmacy benefit managers.
Nehad Soloman, MD: Thank you, Bob. Today we’re going to discuss challenges in the management of rheumatoid arthritis [RA]: how the trial-and-error approach to treatment selection and continued use of ineffective treatments impacts quality of life in rheumatoid arthritis. We’ll discuss tools available to guide treatment selection and how personalization of care can improve treatment outcomes in rheumatoid arthritis. Let’s get started with our first topic. As we know, treatment options available for rheumatoid arthritis may include conventional synthetic DMARDs [disease-modifying antirheumatic drugs], biologic DMARDs, and targeted synthetic DMARDs. Joy, describe the patient journey from traditional synthetic DMARDs into biologic and targeted DMARDs?
Joy Schechtman, DO: This is the most important area in dealing with that patient journey. When we make a diagnosis of rheumatoid arthritis, many of our patients are quite young. They may have very active disease that has impacted them greatly in their social life and family lives, and it affects childbearing as well. For 20 years I ran the children’s rehab services clinic. Some of our patients are at a pediatric age, with juvenile idiopathic arthritis. When we make the initial diagnosis, it’s very scary for patients. As rheumatologists, we know that the clock is ticking. We want to get them on the right medications very quickly. A lot of times, it’s impacting the patient psychologically as well. We have to take a lot of time explaining the process and medications to them, sitting down with them.
We have to talk about the good and bad with medication—the adverse effects. As rheumatologists, we know all the good, but sometimes patients will concentrate on the negativity of medications. We have to explain to them what the disease is. We have to start talking to them about treatments. Normally, I’m going to start with an oral medication, a disease-modifying drug… If they’re young, we may have to talk to them about some type of birth control because of risk in pregnancy.
We’re also faced with some of the challenges from when the patient goes to the pharmacy because of how the pharmacist may talk to those patients… When I talk to them, I like to give them a whole gestalt of what’s available. I go through an overview of all the medications that we may need to use. I say that we’re going to start with plan A. Then we’re going to see how we reassess at frequent monitoring times. I like to see my patients back very frequently in the beginning and check for any adverse effects of medications. Then we’ll see how they do over a period of time. If that’s not the right medicine, we need to go onto the next medicine. I can’t always tell which medicine is going to work the best for you.
We need to start that rapport with the patient, and each patient is a little different. Some patients want to get treatment very quickly. Pain and fatigue are big motivators for patients. When patients are in a lot of pain, they want to get on medications quickly. Part of what I’m doing is trying to get them on the right medicine from the start so I can develop that trust relationship with that patient. For example, methotrexate is probably the No. 1 medicine that most rheumatologists use in the United States. [After I start them on it, I’ll] see them back. If it doesn’t seem like we’re capturing when we’re looking at their joint counts and how they’re feeling—we do several markers—then I want to quickly get them to what I refer to as biologic agents. That’s how I’d start. If those medications were not effective, then I may change that mode of action.
From there I’d look at some of the targeted treatments as well. The disease-modifying drug is the first 1 I’d go to. If they’re not getting the response quickly, I try to get into the biologic medications. That’s how I try to go with those patients. Sometimes patients want to slow down; they’re anxious. We have to spend a lot of time talking about mechanism of action—how these medicines work, how they’re going to impact their daily live, how that’s going to help them with family issues or children and all aspects of disease. From there we’ll move to other modes of action if those medicines aren’t effective.
Nehad Soloman, MD: Thanks, Joy. Clearly, the patient journey is heterogeneic and somewhat complex.
Joy Schechtman, DO: Absolutely. It’s very complex.
Nehad Soloman, MD: Itincorporates a lot of patient-reported outcomes and symptomatology.
Joy Schechtman, DO: Absolutely.
Nehad Soloman, MD: Bob, tell us a little about some of the patient journeys you’ve seen.
Robert Levine, MD: I’ll echo a lot or most of what Joy said. [When we] approach a patient who’s getting their first diagnosis of rheumatoid arthritis, we have to portray this as a serious disease because it could impact their life. But we also have to instill hope and a positive outlook. I tell a lot of patients that years ago, before the biologic era, 50% of patients with RA were disabled after 10 years.
Joy Schechtman, DO: Absolutely.
Robert Levine, MD: They were on disability. I tell them that it’s so much different now; we have many more tools that are much more effective. We need to find the path and the right answers for you as an individual. Those treatments need to be individualized. Not every patient responds to the same algorithm. It doesn’t work for everybody. It’s got to be individualized.
Joy Schechtman, DO: Absolutely.
Robert Levine, MD: Personalized. But we have to give them hope that we’re doing much better now. I used to be able to have my waiting room full of patients in wheelchairs with deformed joints. I could see across the room that this was a patient with rheumatoid arthritis. Now it’s much different. You can’t even tell they have rheumatoid arthritis from the waiting room or anywhere you see people in public. Many of these patients do have rheumatoid arthritis. We must give them a positive framework. That greases the skin, so to speak, for when you talk about medications and different treatment approaches and the specifics of how we’re going to get them there. That’s key: giving them that positive framework.
Nehad Soloman, MD: I concur. Exactly.
Transcript edited for clarity