On cost containment, apart from identifying those most at risk of disease progression to target the costly targeted therapies, the other equally important mission is to ascertain the shortest possible timeframe to achieve the goal of remission, for at least 2 reasons:
1) Patients are better able to count the cost and bite the bullet to pay forward (in terms of paying for costly targeted therapies or bear with the side-effects of steroids) if there is an end in mind;
2) Even if cost is no issue and short-term side-effects are tolerable, infective and other therapy risks are cumulative, much like playing Russian roulette.
To this end, I typically pitch a best-case-scenario 3-month course of remission induction, with a minority perhaps needing up to 6 months of intensive treatment with targeted therapies or moderately high dose steroids, possibly tailing down dose or dosing frequency according to response.
Why 3 months? I think that is the minimum duration a dysregulated immune system needs to wind down, since the much touted "window of opportunity" for "reversing/arresting" the natural course of early inflammatory arthritis is often estimated at 3 months. Also, the duration most conventional DMARDs take to "kick in" to maintain remission is about 3 months too.
No, I admit there is no evidence (yet) that 3 months is the workable minimum, apart from my anecdotal "success" with this strategy in about 80% of patients (which may well represent the proportion who would have responded anyway, had they not chosen the "fail-safe" option to "over-treat"). The OPTIMA trial came closest to suggest that 6 months of induction with Adalimumab + MTX may suffice for most treatment responders.
And with today's post, the depth of response at 3 months predicts continuation of response at 6 months. 3 months certainly looks like a make-or-break point.
If we want patients to do as we say (T2T: Treat-to-Target), we need to align their goals and concerns with our treatment strategy.
What are the patients' goals and concerns? As enumerated in an earlier post, they are to relief pain fully, restore function quickly, and cure eventually; all these achieved without side-effects and at low cost.
Modified by our reality check, the compromise contract looks like: relief pain substantially, restore function fully, and drug tapering eventually; with effective risk management and manageable cost. The former "goals" are achievable (evidence-based) only through a F&F (Fast-and-Furious) induction of remission, while the latter "concerns" are best addressed by commitment to WIT (Whatever-It-Takes) treatment options and close monitoring.
We may need to incorporate communication and counselling modules into undergraduate medical training.
"It’s best to embrace the concept of over-treating every patient to remission. Because you don’t know until it’s too late."
I'm heartened to note that a highly experienced rheumatologist like John Cush shares my treatment philosophy: F&F T2T WIT.
Positive communication is paramount. Make sure we follow up the critical Bad News with hope-giving Good News to engender positive action.