Implementation Barriers Remain
David S. Pisetsky, MD, PhD, professor of medicine and immunology at Duke University School of Medicine, Durham, N.C., and an associate editor of the Annals of the Rheumatic Diseases, concurs the study underlines the recommendations of adding biologics if the disease indicators are present. However, he says, such recommendations raise a number of challenges.
“Part of the challenge is more prompt identification of patients who present with signs and symptoms of inflammatory arthritis,” he explains. “In treat to target, one of the priorities is early recognition by providers that a patient has an inflammatory arthritis.” Primary care providers may not be experienced enough to recognize the signs. And with the shortage of rheumatologists, access to the proper assessments can be delayed in certain places in the U.S. and other countries.
“The importance of these data is they show that there are features that bespeak the need for more and early therapy,” Dr. Pisetsky says. This may entail more frequent and intensive visits early in the course of disease, and require more precise measures of disease activity.
“Primary care providers are being given many responsibilities,” he says. “Where does recognition of RA fit in? Some kind of triage system may be necessary to ensure patients with inflammatory arthritis are seen soon after presentation.”
Possible solutions may lie in using allied providers trained in assessments or telemedicine consults with rheumatologists who can direct the primary provider on which laboratory tests to order. But another issue that’s raised by treat-to-target recommendations is access to more expensive medications, at least in the U.S., says Dr. Pisetsky.
“Rheumatologists often discuss how much time they spend getting approval of medications,” he says. “We rheumatologists want early access for patients, we want [primary care providers] to recognize symptoms, we want an effective screening strategy to get those people who have a likelihood of inflammatory arthritis to us, and then we have to have the time to evaluate patients and educate them. [A diagnosis of RA] is a big change in someone’s life.”
Disclosure of and education about this potentially long-lasting, serious condition cannot always be achieved in a 15-minute office visit, Dr. Pisetsky says. “I think we have to figure out ways to do a lot of work efficiently.”
Gretchen Henkel is a health and medical journalist based in California.
References
- Smolen JS, van Vollenhoven RF, Florentinus S, et al. Predictors of disease activity and structural progression after treatment with adalimumab plus methotrexate or continued methotrexate monotherapy in patients with early rheumatoid arthritis and suboptimal response to methotrexate. Ann Rheum Dis. 2018 Nov;77(11):1566–1572.
- Breedveld FC, Weisman MH, Kavanaugh AF, et al. The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis Rheum. 2006 Jan;54(1):26–37.
- Kavanaugh A, Fleischmann RM, Emery P, et al. Clinical, functional and radiographic consequences of achieving stable low disease activity and remission with adalimumab plus methotrexate or methotrexate alone in early rheumatoid arthritis: 26-week results from the randomised, controlled OPTIMA study. Ann Rheum Dis. 2013 Jan;72(1):64–71.