Emerging Issues in Pharmacological Management of Rheumatoid Arthritis: Results of a National Needs Assessment Survey Identifying Practice Variations for the Development of Canadian Rheumatology Association Clinical Practice Recommendations

RESULTS

One hundred sixty-four members of the CRA completed the questionnaire. Sixty-two percent were male and 60% had been in practice for 10+ years. The greatest proportion of respondents resided in Ontario (43%) followed by the western provinces (British Columbia, Alberta, Saskatchewan, Manitoba; 30%), Quebec (19%), and the eastern provinces (New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland; 8%). Just over half of respondents (51%) reported practicing in academic or teaching hospitals and 73% reported that at least one-quarter of their patients were seen for RA.

Initial DMARD treatment strategies for patients with moderate to severe RA were about evenly split between methotrexate (MTX) monotherapy (up to 20–25 mg per week) and MTX combination therapy. Frequency of radiographs varied from every 6 to 12 months, with annual radiographs most commonly reported (49%), and 12%–14% of respondents were unsure if they would obtain magnetic resonance imaging/or ultrasound in new patients with normal radiographs. The most common use of corticosteroids was as temporary bridge therapy (63%), with intramuscular or intraarticular (44%) and oral prednisone 5–10 mg or 10 mg (46%) as the most commonly reported treatment strategies. Most starting doses for MTX ranged from 10 mg to 20 mg per week, with 15 mg most commonly reported (51%), and 25 mg was the most common maximum dose (84%), with only 1% that reported using > 30 mg. Timing for escalation mostly varied between 4 and 12 weeks, with 10–12 weeks most commonly reported (25%). Fifty-six percent used subcutaneous MTX frequently, and only 1% reported never using it (Table 1).

Patterns for initiating biologic therapy varied greatly. Provided that there was unrestricted access, 57% reported that they would start tumor necrosis factor inhibitor (anti-TNF) after 3–6 months of combination therapy [MTX + leflunomide (LEF) = 14%; MTX + hydroxychloroquine (HCQ) + sulfasalazine (SSZ) = 33%], 31% after 3–6 months on MTX monotherapy 20–25 mg per week, and 16% immediately in patients with moderate to severe RA. After failure of 1 anti-TNF, 68% reported they would switch to a second anti-TNF, and 32% reported they would switch to another mechanism of action [MTX + abatacept (ABAT) = 21%; MTX + rituximab (RTX) = 16%]. There were multiple reasons for switching biologics, with swollen joint count > 5 (70%) and radiographic progression (45%) most commonly reported (Table 1).

The most common safety issues that patients were warned about prior to starting all biologics were pneumonia or serious infections (98%), tuberculosis (96%), injection site reactions (90%), and malignancy (82%). Two-thirds of respondents reported that it was important to ensure vaccines were up to date prior to treatment with anti-TNF or abatacept and 82% prior to RTX. Roughly 50% reported that they would stop MTX prior to surgery, while 90% reported that they would stop biologics (except RTX), with great variability in the timing for suspension. Forty percent believed that treatment with anti-TNF therapy was associated with an increased risk of lymphoma over and above the risk attributable to RA, and 25% and 11% reported that anti-TNF or ABAT and RTX, respectively, were associated with an increased risk of solid tumors.