Treatment Options for Rheumatoid Arthritis (RA)

Vibeke Strand, MD, MACR, FACP:We don’t have much in the way of guidance on what a certain patient might respond to or whether, say, a patient with early RA [rheumatoid arthritis] may do better with one thing than another. Most of it is trial and error. We start usually with a csDMARD [conventional synthetic disease-modifying antirheumatic drug], methotrexate. Some use leflunomide or the combination, and then it’s time for the next step. And that’s where the tsDMARDs [targeted synthetic disease-modifying antirheumatic drugs] and biologic DMARDs come into play. Much of the time it’s the payers who determine what we use because it’s what’s on the formulary, and whatever the pharmaceutical benefit managers have arranged, it would be the least expensive for the patient, but also for the payer. So most of the time, the first thing after methotrexate is a TNF [tumor necrosis factor] inhibitor because that’s where, in fact, the formularies have moved, and that’s where the cost is the most efficient.

All rheumatologists are different in how they assess response. Almost every single one of them is going to do a joint count. But is it going to be all the possible affected joints, or is it going to be the ones that are troublesome? In general, it’s a more limited joint count. There’s a lot of use of RAPID3 [Routine Assessment of Patient Index Data 3] here in the United States, and that’s essentially patient global assessment, pain, and HAQ [health assessment questionnaire]. That often will help with how the patient is feeling. We also have what we call the SDAI [Simple Disease Activity Index] and the CDAI [Clinical Disease Activity Index]. The CDAI is simpler than the SDAI because it has no CRP [C-reactive protein]. So it’s the 2 joint counts and the 2 global assessments, patient and physician. We have criteria for low disease activity and even remission and moderate disease activity, and that’s typically what’s used. DAS [Disease Activity Score] is not generally used in the United States, and the CDAI correlates well with the DAS.

I think physicians are following essentially ACR [American College of Rheumatology] guidelines. Again, EULAR [European League Against Rheumatism] is about DAS. But as I mentioned, we use SDAI and CDAI, and that is also starting to be assessed in European trials. It’s essentially looking at the changes in the above numbers that I told you about, RAPID3, joint counts, and CDAI.

Transcript edited for clarity