Best Practices in Individualizing Rheumatoid Arthritis Care

Best Practices in Individualizing Rheumatoid Arthritis Care Posted By:

Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes progressive damage to the lining of joints. When left untreated, RA can lead to significantly impaired functionality and quality of life. Traditionally, healthcare professionals (HCPs) had limited options to manage RA and the benefits of therapy were tempered by the potential adverse events unique to each option, including methotrexate (MTX), nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. Researchers have worked diligently to develop alternative treatments to improve the disease and patient outcomes. In recent years, several Janus kinase (JAK) inhibitors were approved, however, these agents are also not without potential risks. Targeted biologic disease-modifying antirheumatic drugs (DMARDs) for the management of moderate to severe RA have become central to RA treatment, in hopes of achieving remission of disease or low disease activity. In 2021, the American College of Rheumatology (ACR) published updated guidelines for the treatment of RA to provide direction for HCPs managing RA.

Key Updates in Management of RA

Methotrexate Recommendations
The 2021 ACR Guideline for the Treatment of Rheumatoid Arthritis recommends MTX monotherapy in DMARD-naive patients with moderate to high disease activity. MTX is preferred due to its established efficacy, safety, and low cost. Patients should be started on a dose of ≥15 mg/week with the consideration that the dose may be split for added tolerability.

For patients not at target despite MTX monotherapy, the ACR guidelines recommend the addition of a biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD) to MTX therapy based on patient-specific comorbidities. If the patient is not at target and already on a bDMARD or tsDMARD, they should be switched to an alternative bDMARD or tsDMARD of a different class as an improvement in disease activity and drug survival has been demonstrated.

Glucocorticoid Recommendations
The 2021 ACR Guidelines recommend using the lowest dose of glucocorticoids (GCs) for the shortest duration possible. Patients who achieve their disease activity target should either be started on a DMARD or switched to a DMARD vs continuing GCs, as their improved disease control should allow for reduced GC use. GCs may still be used to alleviate symptoms prior to the onset of DMARD effect. However, to mitigate potential adverse effects of prolonged exposure, GC use should be continually reevaluated to limit total exposure.

JAK Inhibitors for Moderate to Severe RA
In February 2021, the US Food and Drug Administration required warnings about the increased risk of major adverse cardiovascular events (MACE) and malignancy with JAK inhibitors indicated for treatment of RA (ie, tofacitinib, baricitinib, and upadacitinib). This warning was issued after reviewing the ORAL Surveillance trial safety data, which showed an increase in MACE and cancers in patients aged 50 years or older with 1 or more cardiovascular risk factors on tofacitinib compared with patients on a tumor necrosis factor inhibitor (TNFi). Several studies have demonstrated clinical benefits of adding a JAK inhibitor to MTX background therapy. Despite these trial results, the 3 JAK inhibitors used for RA share a common mechanism of action and therefore the FDA recommends that JAK inhibitors only be used in patients with an inadequate response or intolerance to 1 or more TNFi. Current and former smokers are at an increased risk for both cardiovascular events and malignancies, and JAK inhibitors should be discontinued in patients who have experienced a myocardial infarction or stroke.

Individualizing Care in RA
With several agents on the market with varying efficacy and safety considerations, empowering patients to participate in shared decision-making (SDM) is key for individualizing care. SDM is endorsed by the 2021 ACR guidelines, particularly regarding discussing the place in therapy and boxed warnings for JAK inhibitor therapy. HCPs should be equipped to discuss benefits and risks of each class of therapy with patients while choosing the best option with them, factoring in each patient’s medical history and personal goals and preferences.


Filed under: Rheumatology

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