For patients with RA who are suffering primarily from non-inflammatory symptoms, optimizing exercise, patient education, self-management programs, psychological interventions to improve coping and matched goal setting between patient and doctor can enhance care.
It may be helpful to employ ultrasound or magnetic resonance imaging to detect active subclinical disease in cases of difficult-to-treat RA.
Patient Cases
In the 2021 ACR guideline for the treatment of RA, a non-tumor necrosis factor (TNF) α inhibitor, biologic DMARD or targeted synthetic DMARD is conditionally recommended over the addition of a TNF inhibitor in patients with New York Heart Association class III or IV heart failure.2 However, Dr. Haque pointed out the management of these patients is complicated by an increased risk of major adverse cardiac events in patients treated with tofacitinib, as evidenced by the ORAL Surveillance study.3 Thus, although heart failure was not included in the study’s major adverse cardiac events category, it would be reasonable to worry about the potential cardiovascular effects of Janus kinase (JAK) inhibitors in patients with pre-existing heart failure.
Dr. Haque described a patient with RA who had been well managed with leflunomide and adalimumab. However, during the course of care, the patient was found to have myasthenia gravis. This new diagnosis prompted Dr. Haque to ask: Is there a link between RA and myasthenia gravis? Is TNF inhibitor therapy contraindicated in patients with myasthenia gravis?
For both questions, a definitive answer based on the literature does not exist, but Dr. Haque noted that both leflunomide and methotrexate have shown some degree of steroid-sparing efficacy in the treatment of patients with myasthenia gravis. Regarding biologics, some data exist for the use of tocilizumab, tofacitinib and abatacept to treat myasthenia gravis. Perhaps the most robust evidence exists for rituximab, which has been used to treat refractory cases of myasthenia gravis.
On the subject of demyelinating diseases, Dr. Haque noted that methotrexate, leflunomide, abatacept and rituximab may all be appropriate treatments for patients with concomitant RA and multiple sclerosis. However, the use of tocilizumab and tofacitinib must be approached with caution due to case reports of central nervous system demyelination associated with these medications.
Regarding the co-management of patients with specialists in other fields, Dr. Haque described a patient with RA and compensated alcoholic cirrhosis. When using any biologic agent, she noted, it’s vital to co-manage such patients with a hepatologist, who can closely monitor hepatic parameters, and to recognize that limited data exist on the long-term safety of various RA medications for these patients. In terms of conventional synthetic DMARDs, hydroxychloroquine and sulfasalazine appear to be relatively safe. Among biologic treatments, TNF inhibitors, abatacept and rituximab may also be appropriate. Dr. Haque noted that patients with significant renal insufficiency require special attention when selecting appropriate therapy.
