Experts Discuss Unique Challenges Posed by Difficult-to-Treat RA

With many efficacious drugs available, rheumatologists should switch to other agents when the ones currently used clearly do not work in difficult-to-treat RA patients, said Josef Smolen, MD, emeritus professor of medicine at the Medical University of Vienna.

Some reasons RA may be difficult to manage include lack of patient adherence, such comorbidities as heart disease and ILD, and refractory RA. A few key studies have focused on the definition of refractory RA, Dr. Smolen said, with one recent study from the European League Against Rheumatism defining it as moderate to high disease activity after one conventional and two biologic DMARDs have failed.^4,5

Dr. Smolen shared a flow chart he and his co-authors recently published that suggests a possible timeline for treating refractory RA. This includes changing the biologic DMARD or Janus kinase inhibitor to see if the patient improves by three months or reaches their treatment target by six months.⁶ Trying a new treatment within a certain time period instead of relying on a treatment that doesn’t work can help eliminate the unnecessary use of medications, he said.

Liver Disease & RA

Concurrent liver disease with RA presents its own set of challenges, said Stanley Cohen, MD, clinical professor in the Department of Internal Medicine at UT Southwestern Medical Center and co-medical director of the Metroplex Clinical Research Center, Dallas.

Liver disease is not an extra-articular manifestation of RA, but certain liver diseases commonly appear in RA patients. Those include nonalcoholic fatty liver disease, concomitant autoimmune liver diseases, infectious hepatitis, and hepatitis B and C. Although hepatitis C is now less common due to the availability of new treatments, hepatitis B is still a factor rheumatologists must consider before starting therapy, Dr. Cohen said.

Dr. Cohen shared facts about hepatitis B reactivation while discussing the case of a 64-year-old woman with symmetric polyarthritis who was found to have hepatitis B reactivation. The World Health Organization estimates 257 million people around the globe suffer from chronic hepatitis B. Patients can be asymptomatic, or they could have liver failure or even die from the viral reactivation. However, screening and management can help prevent reactivation, Dr. Cohen said.

With many efficacious drugs available, rheumatologists should switch to other agents when the ones currently used clearly do not work in difficult-to-treat RA patients.

Rheumatologists should screen patients for hepatitis B or C before starting new DMARD therapy, Dr. Cohen said, noting many practitioners don’t do this. In addition, rheumatologists should follow the ACR’s 2016 guideline regarding hepatitis B and DMARDs and biologics to treat RA.⁷ One recommendation from the guideline is that in patients starting rituximab therapy who are hepatitis B core antibody positive, prophylactic antiviral therapy is strongly recommended, as opposed to just monitoring liver enzymes and viral load. This is also recommended regardless of hepatitis B surface antigen status.