It is important to give subcutaneous methotrexate the same day each week, Dr. Kremer said. Splitting the dose up on multiple days can lead to toxicity (e.g., bone marrow, gastrointestinal, hepatic), as compared to once-a-week dosing, Dr. Weinblatt added.
Cardiovascular Risk: Anti-TNF, Steroids
Regarding how cardiovascular risk factors in to the decision to use anti-TNFs for an HLA B27–positive patient with inflammatory arthritis, Dr. Ritchlin recommended having a discussion with the patient about the evidence that carotid artery intimal medial wall thickness declines in PsA patients on these agents. There is no evidence yet on patients with other forms of spondylarthritis, he added.
The major comorbidity with COBRA is cardiovascular disease, Dr. Kremer noted. COBRA, based on the Dutch acronym Combinatie therapie Bij Rheumatoide Arthritis, is a combination therapy for treating early RA that consists of three DMARDs, including methotrexate, sulfasalazine, and an initial period with a high dose of prednisolone (60 mg/d tapered in six weeks to 7.5 mg/d). Although it has not been investigated thoroughly enough, Dr. Kremer said, he cited a paper by Greenberg et al that showed there is an increasing risk for CV disease with prednisone doses of >2.5 mg per day.1 “It’s irresponsible to advocate those doses of steroids until someone does know [what the implications are],” he said.
Serial Testing: Immunoglobulin, Imaging
The general consensus among the panelists is that when it comes to immunoglobulin testing in patients on rituxan, serial testing is generally not helpful or cost effective. Measuring immunoglobulin levels in patients on chronic rituximab at the outset of treatment is valuable, Dr. Matteson said, because patients who already have low levels before starting rituximab are at a higher risk of infection. However, the panelists agreed that if immunoglobulin levels decline over time as evidenced by serial testing, that information is not useful for guiding treatment.
Serial imaging—X-ray, ultrasound, and magnetic resonance imaging—are prescribed in guidelines for patients who have RA or PsA, Dr. Weinblatt said, but “is it cost effective or would it change what we do?”
Dr. Matteson and Dr. Kremer came down firmly on the con side of the argument, especially for patients with stable disease. It depends on the patient, according to Dr. Ritchlin. “If you have a patient with [PsA] who achieves minimal disease activity on anti-TNF, we’re not going to be repeating imaging studies,” he said. “For patients with evidence of active disease, we will [repeat imaging studies] to ascertain whether there’s ongoing inflammation that we’re missing and to look for progressing erosions.”
