Practical Aspects of Therapeutic Intervention in Rheumatoid Arthritis

EARLY DIAGNOSIS OF RA

Timely assessment is a relatively new concept in the management of patients with RA^2,3. In the past decade, rheumatologists have come to recognize the importance of early treatment in improving outcomes for RA patients⁴. With increased understanding that the illness experience is vastly different for patients with early-versus late-stage disease, treatment philosophies and discussions surrounding the risks and benefits of treatment have evolved to account for the differences in these populations. Maintaining tight control over disease activity⁵ and treating to target⁶ are newer concepts that are showing promising results. New treatment paradigms utilizing the early use of combination disease modifying antirheumatic drugs (DMARD) have greatly advanced the treatment of early RA and revolutionized outcomes⁷. In particular, data are beginning to accumulate regarding the use of new biologic therapies, which are showing promise in the early treatment of RA⁸.

ROLE OF THE PATIENT

With growing awareness and education surrounding RA, largely due to the recent changes in management options, patients are assuming a greater role in therapeutic decision-making. Empowering patients results in greater concordance with treatment⁹ and satisfaction with care¹⁰, and the potential for improved outcomes¹¹. As a result, patient-driven outcome measures are becoming more common in the management of RA, as discussed by George Wells in this supplement series¹².

Surveys of patients with RA suggest that they want to be fully informed about the risks associated with medications and about alternative treatment options. In a US survey of 100 patients belonging to a community rheumatology practice, the preference for full disclosure about their RA was stronger among women, employed people, and those with higher education¹³. A survey of 344 patients with RA in the United Kingdom examined the relation between patients’ desire for disease information and their involvement in treatment decisions¹⁴. The majority of patients (80.8%) felt that they should be provided with information about their disease, whether they ask for it or not. In cases where there is more than one way to treat a problem, almost all patients (98.2%) agreed that they should be informed about all of the options. However, the majority of respondents (74.5%) also agreed that important medical decisions should be made by the physician, rather than by the patient. Another study of 649 patients with RA in a United Kingdom rheumatology clinic found that the majority (66%) preferred either to relinquish the decision-making entirely to the physician or to make a “forced/informed” choice, whereby the physician explains all of the options, and then ultimately makes the decision regarding therapy¹⁵. Only a third of patients expressed a desire to make treatment decisions themselves.

The desire for involvement in treatment decision-making, therefore, appears to be strikingly low compared with the desire for information. Information-seeking may not necessarily be associated with decision-making preferences. This implies that patients with RA want to be informed, but they do not necessarily want to be burdened with the final decisions regarding therapy.

With respect to patient preferences for therapy, a number of factors need to be considered, including route of administration (e.g., oral, intravenous, subcutaneous), place of administration (e.g., home or clinic/hospital), and dosing interval (e.g., once-daily, weekly, biweekly, monthly). In a survey of 100 consecutive patients with RA who attended a rheumatology outpatient clinic in the United Kingdom, patients were asked about their preferences with respect to anti-tumor necrosis factor (TNF) therapies¹⁶. Half the patients were currently undergoing treatment with an anti-TNF therapy, and the other half were being treated with conventional DMARD. Patients were asked to select their preferences regarding the route of administration, the frequency of administration, the treatment environment, and the individual responsible for administering therapy. When asked to rank each of these 4 variables in order of importance, route of administration was identified as the most important feature of anti-TNF therapy. For patients who were currently being treated with an anti-TNF therapy, the preference was for subcutaneous injection, followed by intramuscular, and then intravenous injection (Table 1). For patients who had not yet been treated with an anti-TNF therapy, the preference was still for subcutaneous injection, but intravenous injection was ranked second, and intramuscular injection third. These results imply that, although intravenous administration is the least preferred method of administration, patients may become accustomed to it once switched to an intravenous therapy. Not surprisingly, the majority of patients preferred to receive their treatment at home, at the longest (bimonthly) interval possible. Chilton, et al surveyed 649 patients with RA in a United Kingdom rheumatology clinic to explore their treatment preferences when faced with 3 options for anti-TNF therapy: etanercept, adalimumab, and infliximab¹⁵. Patients who were not currently undergoing treatment with an anti-TNF therapy were asked to complete a written questionnaire by mail. One-on-one interviews were conducted with those who were currently being treated with an anti-TNF inhibitor. With respect to the route of administration of RA therapy, younger patients were more confident about self-administering treatment, and preferred subcutaneous over intravenous medication¹⁵. Reasons for this preference included not wanting to travel to the hospital, and not wanting to rely on others for assistance. In contrast, older patients were less sure about their ability to administer medications and expressed a preference for the intravenous route, which provides the opportunity for contact with healthcare staff and reassurance that help is available if needed. It is important for rheumatologists to be aware of these differences when helping patients make treatment decisions, as physicians can potentially impose their own lifestyle preferences on patients when prescribing a route of administration.

Despite the increasing use of home infusion strategies, few published studies have compared outcomes between home and hospital infusion, and none in the treatment of RA. In a prospective randomized trial of adults requiring intravenous antibiotics, patients were randomly assigned to complete therapy at home or in the hospital¹⁷. Home intravenous therapy was well tolerated, less costly, and not associated with any major disadvantage to quality of life or clinical outcomes compared to hospital therapy. Nicolay, et al investigated the impact of weekly subcutaneous self-infusions at home on health-related quality of life, treatment satisfaction, and preferences in patients who had previously been treated with intravenous therapy at the hospital/doctor’s office or at home for primary immunodeficiencies¹⁸. Patients reported significantly fewer limitations to their daily activities, improved vitality, and better overall health with home infusions.

In the pediatric setting, preferences for home- versus hospital-based chemotherapy have been evaluated in children with cancer. In a qualitative analysis of children switched from hospital to home chemotherapy, the majority of parents and children preferred home chemo-therapy over hospital chemotherapy¹⁹. Reasons for the preference included lower cost, fewer time constraints, and less disruption to work and family schedules. While some parents felt more secure with hospital chemotherapy, they also found it more exhausting and stressful. Home infusion strategies may therefore be a viable alternative for the treatment of both adults and children with RA.