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My Stepwise Approach to DMARD, Biologic and Targeted Synthetic Use in RA patients
QD Clinic is sponsored by RheumNow.com's coverage of ACR 2021 (November 5-9, 2021)
Disclosures
The author has no conflicts of interest to disclose related to this subject
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Always enjoy your comments but because"no-one" appreciates the efficacy of antimalarials alone if given to early disease we published ~50 pts sen in one year in complete remission ,all of whom had had Anti CCP pos disease mainly early onset, and doesn't include palindromics 90% of whom respond completely Tony R
Tony thanks for this input. While there may be a place for HCQ, my point is that I dont know who, and im not willing to try every new RA on the safest but least effective of choices. This is of course my opinion. I think there are many rheums who do use HCQ as you suggest. I tend to be more aggressive because I dont really know who is going to have bad RA in the end, and my first choices are my most important choices. Fred Wolfe said long ago, use your best drug first...I agree with this.
WHEN TO USE TOCILIZUMAB
As said in the video-
after TNFi
Especially in patients who are "Rule positive" = CCP+ and CRP > 12.3 mg/L
I agree with your approach, start 6+ weeks of MTX +/- low dose prednisone (5mg). A more vexing situation is the patient who is suspected of having RA on the basis of steroid responsiveness, history and exam who have negative/non-diagnostic labs, x ray, and comorbidities with no allergic, infectious or neoplastic etiology apparent. Of course, the first thing to rule out is fibromyalgia! A trial of hydroxychloroquine for 6-12 weeks is reasonable in this scenario as symptoms permit until matters come into better focus. On occasion I have had unexpected responses to Plaquenil when diagnostic uncertainty existed. Remember monocyclic vs polycyclic clinical course of RA from the old days! When all else fails, taper off the prednisone and see what happens clinically. Diagnostic and therapeutic flexibility beats dogma, habit and non-critical thinking.
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