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Questionnaire Items Mode (%) Commonly Reported Strategies (%) Comments General Targets/outcomes used to guide treatment decisions Swollen joint count (94) Morning stiffness (81), radiographs (80), tender joint count (80), ESR/CRP (76), patient global (65), HAQ (52) 42% use gestalt; 28% use DAS28: < 5% use other composite measures such as ACR score, CDAI, or SDAI Starting therapy* Scenario: New DMARD-naive patient (RF+, 6 SJC, 9 TJC) MTX up to 20–25 mg (53) HCQ + MTX (45), HCQ + SSZ + MTX (21) 5% start HCQ alone; < 5% start MTX + LEF; < 3% start MTX + biologic; < 2.5% start SSZ alone Frequency of radiographs Annual (49) Every 6 mo 1 st yr then annual (16); annual until progression stops (11) 5% obtain only if treatment changed; < 5% obtain every 6 mo until progression stops; 14% reported “other” Obtain MRI/US Scenario: New RA patient with normal radiographs MRI: No (49); US: No (64) MRI: Yes (37); US: Yes (24) MRI: 14% reported “unsure”; US: 12% reported “unsure” Treatment with corticosteroids a. Situations in which believe prednisone should be used in RA Temporary bridge for ≤ 12 wks (63) In whom no other options exists; longterm at lowest possible dose (23) 6% considered as a DMARD; 5% hardly use due to risk/benefit ratio; 3% only use with systemic features b. Treatment strategy
Scenario: New RA patient 7–10 SJCIM or IA (44) Start prednisone 10 mg daily (30); start prednisone 5–10 mg daily (16) 5% don’t use prednisone; 5% use 10 mg daily > 6 mo Treatment with MTX a. Starting dose (per wk) 15 mg (51) 10 mg (30); 20 mg (9) < 5% start with dose < 10 mg; 3% start with dose > 20 mg b. Maximum dose (per wk) 25 mg (84) 20 mg (9) 6% reported max dose of 30 mg; 1% reported max dose > 30 mg c. Timing for escalation 10–12 wks (25) 5/6 wks (22); 4 wks (17); 7/8 wks (16) 10% escalate within < 4 wks; 10% escalate within 13–26 wks d. Use of subcutaneous (sc) MTX Frequently (56) Occasionally (26); if dose > 15 mg (18) 1% reported “never”. Reasons for using sc MTX: to improve absorption, reduce side effects, and better effectiveness. Reasons for NOT using sc MTX: patient refusal and no time to teach it e. Investigations prior to starting* CBC (100); creatinine (99); ALT (96) AST (91); ESR (90) CRP (84); albumin (82); ALP (76); hepatitis B/C serology (69); chest radiograph (60) 43% would order a pregnancy test; 38% would order bilirubin; 10% would order TB skin f. Investigations for monitoring* CBC (99); ALT (93); AST (86) Creatinine (79); Alb (65); ALP (54) 48% would order ESR; 38% would order CRP g. Frequency of monitoring Every 4 wks (52) Every 6 or 8 wks (41) Every 12 wks (6%) h. Situations to suspend therapy* Female attempting conception (98) Bacterial infection requiring antibiotics (78); zoster (71) 81% suspend > 3 mo prior to female attempting conception; 76% suspend in male with partner attempting conception; 40% do NOT suspend prior to surgery i. MTX combinations agreed are safe and effective to use* MTX + ETN (90); MTX + ADA (88); MTX + INF (87) MTX + SSZ + HCQ (83); MTX + ABAT (62); MTX + RTX (56) 37% agree that MTX + LEF is safe and effective to use Treatment with biologics a. When to start anti-TNF
Scenario: Patient with moderate to severe RA (assuming no access issues)After failure 3–6 mo MTX + HCQ + SSZ (33) After failure 3–6 mo MTX 20–25 mg (31) 16% start immediately; 14% start after failure of MTX + LEF; 6% reported “other” b. Factors rated as somewhat and very important when initiating a biologic* Effectiveness (99); safety (98); halt radiographic progression (96) Patient preference (87); reimbursement (86) 54% rated mechanism of action c. Biologic side effects warn patients about* Pneumonia or serious infections (98); TB (96); site reactions (90) Lymphoma (82); opportunistic infections (72); demyelinating disease (61); congestive heart failure (36); lupus-like reactions (34); solid malignancies (34); traveling to TB endemic area (23) After an initial discussion, 30%, 66% and 4% always, occasionally, and never warn patients about biologic side effects, respectively d. Strategy after failure of anti-TNF*
Scenario 1: Failure of anti-TNF+ MTX and flare of 4+ joints after 2 visits (assuming no access issues)2nd anti-TNF + MTX (68) ABAT + MTX (21); RTX + MTX (16) 5% reported “other” e. Treatment with RTX When to provide next set of 3 infusions Beginning to flare (73) After 6 mo (15); after 9 mo (10) 2% provide next infusions at full flare; 43% would retreat with a minimal first response to get a better response F. Reason to switch biologics* SJC > 5 (70) Radiographic progression (45); SJC > 10 (36); DAS28 (36); patient decides therapy is not effective (33) Switches based on response with composite measures: DAS28 > 3.2 (21%); DAS28 > 2.6 (15%); SDAI > 11 or CDAI > 10 (< 5%); 29% would not switch therapy if patient is substantially better than when they first started the biologic regardless of disease activity -
↵* Can provide more than 1 answer. ACR: American College of Rheumatology; CDAI: Clinical Disease3 Activity Index; SDAI: Simplified Disease Activity Index; HAQ: Stanford Health Assessment Questionnaire; SJC: swollen joint count; TJC: tender joint count; MTX: methotrexate; HCQ: hydroxychloroquine; SSZ: sulfasalazine; LEF: leflunomide; CBC: complete blood cell count; ALT: alanine aminotransferase; ALP: alkaline phosphatase; AST: aspartate aminotransferase; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; ETN: etanercept; ADA: adalimumab; ABAT: abatacept; IM: intramuscular; IA: intraarticular; TB: tuberculosis.
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