SAN FRANCISCO—Several converging currents put rheumatologists at risk of being caught in “the perfect storm,” believes Eric D. Newman, MD, director of rheumatology and vice chair of the Department of Medicine at the Geisinger Medical Center in Danville, Pa. Traditional healthcare faces increasing problems, therapies for rheumatoid arthritis (RA) are more effective but complex, and outcome expectations are increasing. But, as Dr. Newman and his fellow presenters at a session at the October 2008 ACR/ARHP Annual Scientific Meeting titled “2008 ACR Rheumatoid Arthritis Treatment Recommendations: How Can We Treat Our Patients Better?” proposed, the ACR’s proactive stance on treatment recommendations for RA can help rheumatologists chart a course for the future.
In June 2008, the ACR unveiled the results of a prodigious work effort, “American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis.”1 The ACR session complemented these efforts by offering practical tools to implement the recommendations in a practice-based approach.
RA Care Changing Rapidly
Believing that evidence-based clinical practice recommendations are necessary for increasingly busy clinicians, the ACR had asked a task force panel to address five objectives regarding the use of nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) in patients with RA:
- Their indications for use;
- Assessing clinical response;
- Screening for tuberculosis (TB; biologics only);
- Monitoring for side effects; and
- The roles of cost and patient preference in decision making (biologics only).
First, presenter Kenneth G. Saag, MD, professor of medicine and epidemiology at the University of Alabama in Birmingham, was a member of the core expert panel that conducted the extensive literature review and helped guide, along with the working group, the development of the recommendations. An expert task force panel used a modified Delphi process to reach consensus and enrich response categories for clinically detailed scenarios that would lead to RA treatment strategies.
The resulting recommendations comprise a dynamic document, Dr. Saag pointed out. “These recommendations provide a framework for future efforts. Although they’re extensive in scope, they are not comprehensive. They are meant to complement but not to eclipse individualized patient care,” he said. Some of the newer biologic agents were not included in the recommendations because the evidence to date was insufficient to elicit consensus by experts. Dr. Saag hopes that future updates of the recommendations will address the effectiveness of switching biological medications of the same mechanism (e.g., TNF blockers) and sequential biologic therapies, among other questions.
Measure, Measure, Measure
One of the key themes introduced by the recommendations is the necessity to regularly appraise patients’ symptoms and responses to treatment. For instance, because treatment algorithms are keyed to level of disease activity (i.e., low, moderate, and high), it’s imperative that patients’ disease activity be assessed. The developers of recommendations did not specify which instruments clinicians should use but did say that it ought to be done.