Conversations in Moderate to Severe Rheumatoid Arthritis: Involving Your Patients in Therapy Discussions © Thinkstock by Getty Images
Dear Colleague: As we consider how to approach our decision making in selecting a biologic disease-modifying antirheumatic drug (DMARD), we are confronted with many questions: • Which therapy should I prescribe for each individual patient? • How does maintaining a dialogue with our patients help us select the most appropriate treatment option? • What are our patients' questions, including efficacy and safety issues, for each therapy? • How can we as clinicians better address these questions and educate patients on their disease state and treatments? It is crucial to initiate the conversation with our patients to educate them and select the appropriate therapy for each individual patient. We need to encourage them to feel comfortable enough to express their feelings and ask questions. Additionally, we need to have further discussions to adequately monitor therapies, including by assessing treatment response, disease progression, and adverse events. Sincerely,
Ellen M. Field, MD, FACR FACULTY REVIEWER Ellen M. Field, MD, FACR Rheumatologist Lehigh Valley, Pennsylvania
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hen clinicians decide the most appropriate therapy for their patients with rheumatoid arthritis (RA), efficacy, safety and the needs of each individual patient should be be taken into account. Guidelines are meant to provide a starting point for therapeutic decision making. However, guideline recommendations cannot sufficiently convey all considerations and nuances of patient care. Treatment options should also be based on specific patient characteristics, including comorbidities, concomitant medications, and economic factors, as well as efficacy and safety considerations of each therapy. When reviewing the risks and benefits of therapeutic choices, it is important to individualize treatment discussions.1 Both the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) recommend selecting appropriate treatment based on the individual patient.1,2 In order to gain enough information to meet these needs and appropriately conduct a riskbenefit analysis for each patient, two-way communication between healthcare provider and patient is required.2 PRESENTING THERAPEUTIC OPTIONS Before explaining treatment options, the patient’s goals of therapy should be discussed. The ACR guidelines do not recommend a specific goal for all patients; however, low disease activity is an acceptable goal based on the individual patient.1 Low disease activity can provide relief from joint pain, stiffness and swelling, and may be obtained by using a biologic disease-modifying antirheumatic drug (DMARD).3
RA patients’ previous experiences may lead them to have differing opinions about drug choice recommended by the prescribing physician.4 In order to reduce this discrepancy, when presenting therapeutic options, patients should be provided with a sufficient understanding of their disease. Be sure they are aware of the nature of the disease state and why they are being prescribed a biologic agent. If patients do not understand the significance of their disease and its progressive nature, they may not feel the need to seek treatment.3 ONCE A CHOICE IS MADE When speaking to your patients about their prescribed therapy, be sure to include the following information: • Treatment goals • How biological therapy may help them reach these goals • Important safety considerations • Potential interactions with concomitant medications • Ongoing monitoring. There are additional counseling points based on the administration technique you are considering for your patient ( Table 1). It is important to ensure that patients who have no prior experience in self-injecting biologics understand the responsibilities that are involved, including properly storing the injection devices and safely disposing of them after use. Patients should self-inject after physician approval and proper training. At minimum, patients need to learn about the injection sites and proper injection techniques. Injection devices vary for each medication; it’s critical for the patient to
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TABLE 1. Considerations based on treatment modality. Self-Injection • Treatment is usually self-injected at home, after physician approval and proper training. • The medication is injected under the skin. • The treatment usually comes in an injection device prefilled with the medication. • The patient fills the prescription and stores the medication in the refrigerator. • The patient must dispose of the injection device right away after use in a puncture-proof sharps container. The patient must follow the community guidelines for how to dispose of the sharps disposal container once it is full. Infusion • Treatment will be given at the doctor’s office or at an infusion center. • Before each infusion, weight and vital signs will be assessed. • The infusion is prepared and given by a trained healthcare provider. • The medication is delivered through a needle placed in the vein, usually in the arm. • A healthcare provider will monitor the patient during the infusion. • The patient should be encouraged to ask any questions or report any side effects experienced during or after the infusion to the healthcare provider overseeing the infusion.
understand how to use the specific injection device for the medication prescribed, even if the patient has had previous injection experience with other devices. Patients who have been prescribed infusion therapy should be given a tentative schedule of their appointments, which may be more frequent initially, depending on their individual regimen. They will need to know why it is important that they adhere to a certain schedule. They should understand that the medication is delivered through a needle placed in the vein, and that the healthcare provider will monitor them during the infusion. According to the ACR guidelines, if patients have not received vaccinations, such as pneumococcal, intramuscular influenza, hepatitis B, meningococcal, and human papillomavirus vaccines, they should do so before starting treatment. During treatment with biologic medications, patients should
not receive live, attenuated vaccines because of patients’ immunosuppression.1 Clinicians should set appropriate expectations regarding treatment results. ONGOING SUPPORT AND MONITORING Upon initiation of biologic therapy, be sure to communicate the signs of danger that should alert the patient or caregiver to seek immediate medical assistance. They should be familiar with more common side effects of their therapy as well.5 It is essential to schedule regular followup visits and phone calls to assure patients that their healthcare team will monitor for efficacy and any serious adverse effects. At follow-up visits, be sure to remind patients that their immune systems may be vulnerable to bacterial, fungal, and viral infections.3 Patients should also inform their physicians if they are contemplating pregnancy or breastfeeding, especially if the medication
would require discontinuation or additional monitoring.6 Discuss with your patients how you will measure success and how often they will need to return to the office for follow-up visits and lab tests. In addition to using validated efficacy scales, it is helpful to develop mutually agreed-upon goals with your patients and ask candid follow-up questions as to whether they are progressing as well as they thought they would.7 Appropriate monitoring can help assess whether your patients’ treatments are efficacious and safe.1 Maintaining a two-way dialogue with your patients will not only help select appropriate treatments for them, but also improve your ability to adequately monitor their therapies. REFERENCES 1. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(5): 625-639. 2. Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014;73(3):492-509. 3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on health: rheumatoid arthritis. http://www.niams.nih.gov/Health_Info/Rheumatic_ Disease/default.asp. Accessed September 17, 2014. 4. Scarpato S, Antivalle M, Favalli EG, et al. Patient preferences in the choice of anti-TNF therapies in rheumatoid arthritis: results from a questionnaire survey (RIVIERA study). Rheumatology (Oxford). 2010;49(2): 289-294. 5. American College of Rheumatology. Anti-tumor necrosis factor fact sheet. http://www.rheumatology.org/ Practice/Clinical/Patients/Medications/Anti-TNF/. Accessed September 17, 2014. 6. American College of Rheumatology. Pregnancy and rheumatic disease. http://www.rheumatology.org/ Practice/Clinical/Patients/Diseases_And_Conditions/ Pregnancy_and_Rheumatic_Disease/. Accessed September 17, 2014. 7. Ryan S, Hassell A, Dawes P, Kendall S. Control perceptions in patients with rheumatoid arthritis: the impact of the medical consultation. Rheumatology (Oxford). 2003;42(1):135-140.
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Discussion Guide on Moderate to Severe Rheumatoid Arthritis for Use with Your Doctor
After reviewing your medical history, test results, and the safety and efficacy of various therapeutic options, your doctor has determined that a biologic agent may be the appropriate treatment for your moderate to severe rheumatoid arthritis (RA). In order to select an appropriate treatment for you, strong communication between you and your doctor is important. Biologic agents are medications that help decrease inflammation and structural damage to the joints by interrupting the cascade of events that cause inflammation.The goals of your treatment include relieving pain and decreasing inflammation. Throughout treatment, it is important for you to regularly visit your doctor for routine monitoring and ongoing care. This will help your doctor assess the effectiveness of your treatment, including negative effects of medications that could necessitate the modification of your treatment plan. Before your doctor decides which medication is right for you, there are a variety of things that you will discuss. Your doctor will discuss: Your overall health Your moderate to severe RA and your symptoms n Important safety considerations n
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Ongoing monitoring How biologic medicines work
Biologics for moderate to severe RA are given in 2 ways—self-injection or infusion—depending on the medicine. Together, you and your doctor will decide which treatment may be right for you. Self-Injection
Infusion
After filling each prescription, the medicine is stored in your refrigerator until it’s time for your injection.
Your doctor prescribes and a healthcare provider stores your medication until your infusion.
You give yourself the injection under the skin after physician approval and proper training.
The infusion is prepared and given by a trained healthcare provider.
Where
Treatment is usually self-injected at home.
Treatment will be given at your doctor’s office or at a local infusion center.
How
Treatment is usually self-injected at home, after physician approval and proper training.
The medication is delivered through a needle placed in your vein, usually in your arm.
The medication is injected under the skin.
When you arrive for treatment, a healthcare provider will perform an assessment of your health and check your blood pressure, heart rate, temperature, and weight.
Who
The treatment usually comes in an injection device prefilled with your medication. You will need to dispose of the injection device right away after use in a puncture-proof sharps container. You will also need to follow your community guidelines for how to dispose of the sharps disposal container once it is full.
The medication is delivered through a needle placed in your vein, usually in your arm.
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You can ask your doctor the following questions about biologic therapies to learn more about available treatment options. n
What does my doctor need to know about me before deciding on a treatment?
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How does the medicine work?
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How long does it take for the medicine to start working?
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How will I know the treatment is working?
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How often will I need treatment?
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When will my treatment take place?
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How will my treatment be administered?
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What are possible side effects of treatment?
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What are the most important risks I should know about this treatment?
Talk with your doctor to learn more about biologic medicines for moderate to severe RA and if one is right for you.
REFERENCE National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on health: rheumatoid arthritis. http://www.niams.nih.gov/Health_Info/ Rheumatic_Disease/default.asp. Accessed September 17, 2014.
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