Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force
The overarching NEED in RA treatment, the rheumatologist's mission, is the early and effective abrogation of inflammation, so as to prevent irreversible joint damage and permanent disability. This we have had increasing success with a treat-to-target (T2T) strategy, by employing the vast therapeutic advances at our disposal to achieve full clinical remission or very low disease activity.
The unmet EXPECTATIONS, however, are the patient's sole prerogative. Ultimately, this is how the success of our therapeutics and strategy will be judged.
So what are these "Unmet Expectations" I encounter in daily clinical practice?
1) Patients expect the treatment to act fast and act fully to relieve their pain and restore their function/lifestyle.
2) They expect the drugs not to cause any side-effects.
3) They expect the administration to be convenient (oral or long-interval injection) and to give them control (self-titration).
4) They expect to be able to go off medication in the foreseeable future ("no longer than is absolutely necessary"): "on-demand" therapy if no permanent cure.
Managing expectations is far tougher than managing disease. How do I manage (struggle)?
First and foremost, I prioritize on what is most important. Amidst expectations of efficacy, safety and convenience/cost, efficacy wins hands-down in choosing treatment.
Taking into account economic constraints, only the 15-20% who are likely to do badly should be started on a targeted therapy early. The next step is to choose the best drug that the patient will respond to.
Therein lies our problem: we still can't predict very well who will do badly, and which drug suits who best. We have high precision weapons, which we haven't "zeroed" accurately to hit the target. Welcome to the brave new world of targeted therapies and the overhyped promise of individualised medicine. We just shot ourselves in the foot.
Choosing who to escalate earlier to targeted therapy is the easier part compared to deciding which expensive drug to use in whom. The bad prognostic indicators for rapidly-damaging, difficult-to-control, and non-abating disease have been known for some time:
1) ACPA & RF positive (especially if high titre),
2) high ESR/CRP at presentation (I disagree),
3) joint erosion/damage already evident at presentation,
4) inadequate response to initial appropriately aggressive treatment... (this I consider as most telling).
Of course, if cost is manageable, I'll rather over-treat and risk the rare side-effect, than under-treat and risk irreversible damage.
I'm almost embarrassed to admit to my patients that my choice of targeted therapy for their arthritis is guided by the time-honed method of "trial-&-error".
You'd realise reading the posts today that predicting response is still very much an art, because the science of biomarkers is simply not out there in the clinics. Anti-CCP seems to be the consistently reliable and available predictor of response to B-cell depletion, but who uses Rituximab as first line in RA?
Till the prophetic science improves, this is how I make do: I use the short-duration ones (Etanercept, Abatacept, Tocilizumab, Tofacitinib) for a therapeutic trial. If clinical response is anything short of dramatic within a week (or maximum 2), I switch. My patient's finances and my reputation can't take too many failures.
Once I manage the efficacy expectation, the rest (safety, convenience/cost, tapering) are far easier.
While T2T is the overarching principle in managing the patient's disease, the key to managing the patient's expectations is to "Under-Promise and Over-Deliver"😊