Interestingly, because men and women respond differently to methotrexate therapy, the data also suggest women with early RA may benefit from frequent, early disease activity monitoring. This monitoring would allow clinicians and patients the opportunity to adjust treatment as early as the first three months of therapy, the authors note.
“These data confirm the recommendations to really make a major decision [about treatment] at six months. It confirms treat to target. It confirms EULAR, and in some respects, the ACR management recommendations,” says Dr. Smolen. “In the treat-to-target recommendations, we provide two time points: If you have not improved by three months by at least 50%, then you have a very low chance of reaching the good outcome by six months. So if you have less than 50% improvement on the clinical disease activity index, the CDAI, then you should swap already, or add [the biologic].”
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 lay 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.
