Conversations in Moderately to Severely Active 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
W
hen clinicians decide the most appropriate therapy for their patients with moderately to severely active 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, 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 and appropriately conduct a risk-benefit analysis for each patient, two-way communication between healthcare provider and patient is required.2
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 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 PRESENTING THERAPEUTIC • Ongoing monitoring. OPTIONS There are additional counseling points Before explaining treatment options, based on the administration technique the patient’s goals of therapy should be you are considering for your patient discussed. The ACR guidelines do not ( Table 1). Brought to you by Janssen Biotech, Inc.
Dr. Field is a paid consultant for Janssen Biotech, Inc.
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, assess the patient’s health and check blood pressure, heart rate, temperature, and weight. • 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. This chart is not intended to compare the safety, effectiveness, or uses of these treatments. There are other considerations for selecting a biologic treatment.
You may want to discuss that biologic self-injectable treatments are usually injected at home, after physician approval and proper training. Inform patients that the treatment usually comes in an injection device prefilled with the medication, and the medication is injected under the skin. They should fill the prescription and store the medication in the refrigerator. Remind your patients that they must dispose of the injection device right away after use in a puncture-proof sharps container, and must follow the community guidelines for how to dispose of the sharps disposal container once it is full. Patients should be aware that biologic infusion treatments will be given at the doctor’s office or at an infusion center. Explain to your patients that the infusion is prepared and given by a trained
healthcare provider, and the medication is delivered through a needle placed in the vein, usually in the arm. Before each infusion, assess the patient’s health and check blood pressure, heart rate, temperature, and weight. Let patients know that they will be monitored during the infusion. Encourage your patient to ask any questions or report any side effects experienced during or after the infusion to the healthcare provider overseeing the infusion. There are other considerations for selecting a biologic treatment. Patients should know that you will discuss their overall health, their moderately to severely active RA, their symptoms, important safety considerations, ongoing monitoring, and how biologic medicines work. Clinicians should set appropriate expectations regarding treatment results.
ONGOING SUPPORT AND MONITORING It is essential to schedule regular followup visits and phone calls to assure patients that their healthcare team will monitor for efficacy and any adverse effects. Tell your patients that monitoring generally includes visits to the doctor, and may also involve blood, urine, and other laboratory tests. They should understand that good communication between the patient and the doctor is important for treatment. Strong communication can help ensure that medications are prescribed appropriately, and that any additional support patients may need is provided.3 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. Appropriate monitoring can help assess whether your patients’ treatments are efficacious and safe.1 Maintaining a twoway 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.
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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 in joints by interrupting the cascade of events that cause inflammation.The goals of your treatment include reducing 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 side 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.
Where
Treatment is usually self-injected at home, after physician approval and proper training.
Treatment will be given at your doctor’s office or at a local infusion center.
How
You give yourself the injection under the skin 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 infusion is prepared and given by a trained healthcare provider.
A healthcare provider will monitor you during the infusion. If you have questions or experience side effects during or after your infusion, discuss them with the healthcare provider overseeing your treatment.
This chart is not intended to compare the safety, effectiveness, or uses of these treatments. There are other considerations for selecting a biologic treatment. Talk to your rheumatologist about treatment options and what might be right for you.
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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.
Brought to you by Janssen Biotech, Inc.
Š Janssen Biotech, Inc. 2014
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