More than 1 century ago, the great Sir William Osler was quoted as saying, “When an arthritis patient walks in the front door, I feel like leaving by the back door.” At the beginning of my training, it was not uncommon to see numerous assistive devices in the waiting room of the department as the hospital was full of patients undergoing orthopedic procedures for deteriorating joints. Today, it is the opposite, particularly when it comes to patients with rheumatoid arthritis, for whom it seems there is a new world of therapeutic offerings.
The Cover Story of this first issue of Healio Rheumatology explores advances in the treatment of rheumatoid arthritis (RA). Much is being said about the new “American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis.” The guideline is not radically different from its predecessors, but it is still significantly different. It uses a new methodology that was purported to be more transparent and patient-engaged. It also is clinical and favors the common over the uncommon. It also notes the profound socioeconomic influences to which we are now subjected, but unfortunately, are unable to solve at this moment. It is hard to editorialize about the vast array of progress, but I will make some comments in three areas.
The first recommendation in the ACR guideline is a wholehearted endorsement of a treat-to-target strategy, which should be a standard in practice by now. The targeting should incorporate the use of any of six endorsed metrics designed to quantitate disease activity and that remission or low disease activity is our target. However, unspoken are three limitations of this strategy. First, as demonstrated by John J. Cush, MD, in his frequent sampling of practice habits, most rheumatology visits do not incorporate metrics. In addition, a recent abstract at the ACR Annual Meeting showed rheumatologists are missing the frequency of visit target because of the time crunch. Second, we recognize the target itself is a negotiated one by engaging in a shared and informed decision-making process whereby we arrive at it. Many patients may be limited by comorbidities from aggressive therapy. Other patients have lesser goals that need to be heard even if they are in disagreement with ours. Third, there are new metrics, including biomarkers, such as the multi-biomarker disease activity score (Vectra DA, Crescendo Bioscience), which offer additional tools for the appraisal of prognosis. Incidentally, poor prognosis was eliminated from the new guideline. They also offer time-efficient methods for disease activity assessment, which also need to be evaluated and incorporated.
The second area that impressed me was the shift in biologic recommendations away from the standard bearer of tumor necrosis factor (TNF) inhibitors to a more generalized recommendation of any biologic. This clearly meets the current practice patterns of most rheumatologists who no longer cycle through TNF inhibitors to achieve a target. It also encourages one to match the drug and patient earlier in treatment when the particular disease or comorbidities match better with non-TNF inhibitors. However, I am concerned about the less embracing use of the first kinase inhibitor (i.e., tofacitinib citrate) which, while incorporated into the new guideline, seems to be favored in more refractory cases. Kinase inhibitors have shown great promise and are the first agents demonstrated to be superior to methotrexate in outcomes. I predict we will use these drugs earlier in future iterations when we have more experience and safety data.
The third area is one where I must complain a bit — comorbidities. Although I am heartened by the new provisions on how we should approach therapy with hepatitis B (HBV) and hepatitis C (HCV), the screening recommendations for these conditions is definitely “old school.” We have not revised the recommendations on screening since 2008. We also need to be in alignment with other groups who grapple with this same issue, in particular the American Association for the Study of Liver Diseases (AASLD). The AASLD has endorsed screening for HBV and HCV for all patients undergoing immunosuppression. It is simple if you endorse this common sense approach.
I congratulate the team who produced the new ACR guideline. I look forward to the ongoing critical appraisal of how we should use it in everyday practice.
Thank you for reading Healio Rheumatology. With this launch, I hope that Healio Rheumatology and Healio.com/Rheum help you stay current on research and patient outcomes. You can send me your comments by email at firstname.lastname@example.org or on Twitter @LCalabreseDO.
- Di Bisceglie AM, et al. Hepatology. 2015;doi:10.1002/hep.27609.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosure: Calabrese reports he is a consultant for Genentech, Pfizer, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi, Jansen and Abbvie; and is on the speakers bureau for Genentech, Abbvie and Bristol-Myers Squibb and Crescendo Bioscience.