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 CRA e-Newsletter
October 2012
Treating Rheumatoid Arthritis to
Target
Inside this issue:
Patient Profile
Treating Rheumatoid Arthritis
to Target
References
Patient profile
Helen is a 45-year old woman diagnosed with rheumatoid arthritis (RA) 2 months
ago. On physical exam she has 9/28 swollen joints and 12 /28 tender joints; she
also complains of pain in her feet with evidence of synovitis in 5 MTP joints. She
rates her overall disease activity at 7/10; she is RF positive and anti-CCP positive
and her ESR is at 45 and her CRP at 2.2 mg/dL. She had to miss several days of
work in the last 6 weeks. Her GP prescribed naproxen 500 mg BID and some
codeine.
Treating Rheumatoid Arthritis to Target
Rheumatoid arthritis (RA) is a chronic disease that is estimated to affect
approximately 1% of Canadians. 1 Articular and non-articular manifestations of RA
lead to reduced functional capacity and disability. 2 As a result, patients with RA
experience significant productivity losses, impaired psychological well being, and
poorer health-related quality of life. 3-5
Traditionally, the pharmacological management of RA involved a symptomalleviating approach with changes in dosage or the addition of medications only if
symptoms progressed. 6 However, dramatic strides in RA management have now
made long-term remission and prevention of irreversible joint damage a realistic
goal. Important developments over the last two decades have included the advent
of biologic therapies that can alter the clinical course of RA, together with significant
advances in the availability of tools to help guide clinical decisions toward optimal
outcomes. 7-9
Current guidelines recommend a targeted approach to RA management. 10,11
Aiming at specific predefined therapeutic targets in diseases such as diabetes and
hypertension has been associated with a reduced risk of organ failure, but in the
past, such targets had not been defined for RA management. In 2010, an
international Treat to Target (T2T) task force formulated consensus
recommendations aimed at improving the management of RA in clinical practice,
thus providing guidance for treatment to target. 11 The T2T task force, and also the
European League Against Rheumatism (EULAR) 2010 guidelines, 12 refer to
evidence from various randomized controlled studies and observational studies
showing that RA patients who attain remission have better outcomes than patients
who have residual disease activity. The T2T initiative resulted in 10
recommendations (see table below).
Faculty
Boulos Haraoui
MD FRCPC
References
1.
Canada; 2006. View source [Accessed
September 6, 2012].
2.
2.
Clinical remission is defined as the absence of signs and symptoms of
significant inflammatory disease activity.
3.
While remission should be a clear target, based on available evidence, low
Doeglas D, Suurmeijer T, Krol B, et al.
Work disability in early rheumatoid
arthritis. Ann Rheum Dis
1995;54(6):455-60.
3.
Puolakka K, Kautiainen H, Möttönen T,
et al. Predictors of productivity loss in
early rheumatoid arthritis: a 5 year follow
up study. Ann Rheum Dis
2005;64(1):130-133.
4.
Gettings L. Psychological well-being in
rheumatoid arthritis: a review of the
literature. Musculoskeletal Care
2010;8(2):99-106.
5.
Whalley D, McKenna SP, de Jong Z, et
al. Quality of life in rheumatoid arthritis.
Rheumatology 1997;36(8):884-888.
6.
Rindfleisch JA, Muller D. Diagnosis and
management of rheumatoid arthritis. Am
Fam Physician 2005;72(6):1037-47.
7.
Fransen J, Stucki G, van Riel PL.
Rheumatoid arthritis measures: Disease
Activity Score (DAS), Disease Activity
Score-28 (DAS28), Rapid Assessment
Table. Treating rheumatoid arthritis to target: recommendations of an
international task force 11
1. The primary target for treatment of rheumatoid arthritis should be a state of
clinical remission.
Rheumatoid arthritis. Ottawa: Statistics
of Disease Activity in Rheumatology
(RADAR), and Rheumatoid Arthritis
Disease Activity Index (RADAI). Arthritis
Rheum 2003;49 Suppl 9:S214-24.
8.
Fransen J, Häuselmann H, Michel BA,
Caravatti M, Stucki G. Responsiveness
of the self-assessed Rheumatoid
Arthritis Disease Activity Index to a flare
disease activity may be an acceptable alternative therapeutic goal,
particularly in established longstanding disease.
of disease activity. Arthritis Rheum
2001;44:53-60.
4.
Until the desired treatment target is reached, drug therapy should be
adjusted at least every 3 months.
9.
Pincus T, Yazici Y, Bergman M. A
practical guide to scoring a Multi-
5.
6.
Measures of disease activity must be obtained and documented regularly,
as frequently as monthly for patients with high/moderate disease activity or
less frequently (such as every 3 to 6 months) for patients in sustained low
disease activity or remission.
Dimensional Health Assessment
use in standard clinical care, without
Questionnaire (MDHAQ) and Routine
Assessment of Patient Index Data
(RAPID) scores in 10-20 seconds for
The use of validated composite measures of disease activity, which include
joint assessments, is needed in routine clinical practice to guide treatment
decisions.
rulers, calculators, websites or
computers. Best Pract Res Clin
Rheumatol 2007;21:755-87.
7.
Structural changes and functional impairment should be considered when
making clinical decisions, in addition to assessing composite measures of
disease activity.
10. Bykerk VP, Akhavan P, Hazlewood GS,
et al. Canadian Rheumatology
Association Recommendations for
8.
The desired treatment target should be maintained throughout the remaining
course of the disease.
Pharmacological Management of
Rheumatoid Arthritis with Traditional and
9.
The choice of the (composite) measure of disease activity and the level of
the target value may be influenced by consideration of comorbidities, patient
factors, and drug-related risks.
Biologic Disease-modifying
Antirheumatic Drugs. J Rheumatol 2011.
11. Smolen JS, Aletaha D, Bijlsma JW, et al.
10. The patient has to be appropriately informed about the treatment target and
the strategy planned to reach this target under the supervision of the
rheumatologist.
Clinical remission is defined as the absence of signs and symptoms of significant
inflammatory disease activity. In some patients, e.g., those with long-standing
disease, complete remission may not be realistic or achievable; for such patients,
low disease activity may be an acceptable alternative goal. For these patients,
some residual joint tenderness or a single swollen joint may be compatible with a
state of remission. 11 The Canadian Rheumatology Association 2011 guidelines 10
also recommend that remission should be the goal of RA treatment; when this is not
possible, treatment should aim for minimal disease activity while controlling
symptoms, halting damage, preventing disability, and improving quality of life.
Maximal clinical benefit with drug therapy in RA is usually not achieved before 3
months of treatment. By this time, if at least a state of low disease activity is not
attained, treatment should be amended. A change of drugs is not always
necessary, because dosage adjustment of an existing medication may be sufficient
for achieving further benefit. 11 Methotrexate (MTX) is the preferred and most
frequently used first line therapy for RA, and remains an anchor drug to enhance or
maintain the efficacy of biologic agents. Patients who respond inadequately to MTX
may be treated sequentially with another DMARD, combination of DMARDs, or a
biologic agent. 13
Treatment decisions should be guided by using composite measures of disease
activity; these may include the disease activity score (DAS) or the DAS employing
28 joint counts (DAS28), the simplified disease activity index (SDAI) and the clinical
disease activity index (CDAI). X-rays should be obtained 6-12 monthly to estimate
progression of joint damage. Intensification of treatment may be warranted if joint
damage appears to be progressing despite achieving the desired target such as low
disease activity. 10,11
A treatment algorithm as recommended by the T2T task force is provided in the
figure below.
Treating rheumatoid arthritis to target:
recommendations of an international
task force. Ann Rheum Dis
2010;69(4):631-7.
12. Smolen JS, Landewe R, Breedveld FC,
et al. EULAR recommendations for the
management of rheumatoid arthritis with
synthetic and biological diseasemodifying antirheumatic drugs. Ann
Rheum Dis 2010;69(6):964-75.
13. Haraoui B., for the CRA sub-committee
on biologic agents. Canadian
Rheumatology Association Position on
the use of Biologic Agents for the
Treatment of Rheumatoid Arthritis. View
source [Accessed September 7, 2012].
Figure. Algorithm for treating RA 11
Patient profile (contd.)
With her regimen of daily naproxen and codeine as needed, Helen complains that
the relief from her symptoms is unsatisfactory.
Therapy with MTX is initiated, with the MTX dosage being escalated to 25 mg/week
over 2 weeks. Helen’s treatment is adjusted as needed to achieve a target of
clinical remission.
This eNewsletter is provided by an educational grant from Pfizer.