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

VIVIAN P. BYKERK; ORIT SCHIEIR; POONEH AKHAVAN; GLEN S. HAZLEWOOD; CARLY K. CHENG; CLAIRE BOMBARDIER

doi:10.3899/jrheum.110208

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Table 1.

2007 Canadian practice patterns for pharmacological management of RA (N = 164).

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 SJC	IM 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.