QD 92 - DMARD Bailout Save

This is QD Clinic. Hi. I'm doctor Jack Cush with RheumNow. QD Clinic is brought to you by the twenty twenty ACR annual meeting. It's all virtual.

RheumNow will be there. You give us two hours. We'll give you the meeting. Today's case, the DMARD bailout. Saw a gentleman few days ago, 70 year old male, serious, bad, erosive deforming, polyarticular RA, been on a lot of different medicines.

More recently was on prednisone, leflunomide, Xeljanz, and a few other drugs. And at this visit, the patient said, Yeah. I'm no longer taking that leflunomide medicine. And of course, I do my little cocked head, quizzical look. Again, when I'm wearing a mask and goggles, I'm not sure it makes any difference.

And I say, What's that about? And, you know, he told me a story about what happened. And so, and I think the question is how do you handle the, DMARD bailout? Patient, makes the decision, or someone else makes the decision, not you, that, this drug is no longer needed. This could be we could be talking about any drug here, but I'm choosing DMARDs because they're supposed to be disease modifying, and that's the intent by which you gave it.

Hence, patient's not taking it, we're looking at suboptimal therapy, are we not? I think you can think about this in three different ways. The patients bail out on a drug either because of the patient choice or because another MD got involved, or third external forces beyond our control, you know, like a hurricane or something. When the patient chooses to stop the drug for whatever reason, I think rather than getting all pissy and looking at them like, are you crazy? Like, what were you thinking?

You know, these are all my inclinations. I think the interesting thing is to say, well, me what that's all about and tell me how you're doing. Because they bailed out. The question is, was that a good idea or a bad idea? They already have the history that's going give you the answer.

If it turned out to be okay and not a bad idea, there's no point in coming down hard on the patient. If it was a bad idea, you say, gee, that wasn't really a good idea. Either way, you always make the point. I want you to know these medicines I give you, they're mine. I'm the expert.

I wrote the prescription. I'm responsible for it. Think about it like I'm lending you my Mustang, and you can drive it around. I don't want you to paint my Mustang or, you know, you know, drive on the beach with it. You know, certain things you probably should ask for for my permission.

So, before you sell my Mustang, give me a call. The same thing with these DMARDs or biologics. You know, realize that you should let me know when someone else or you wanna do something with my medicine. Otherwise, you know, there's a consequence there that could be damaging, and I don't want that to happen. Call me.

I'll tell you whether you can stop or not or whether you need to stop when you're gonna have surgery or because you're going on vacation, or because someone else wants to stop it, give me a call. Second scenario, the patient stopped because Doctor. Schmo told him we have to stop that medicine now. Surgery, hospitalization, always like seems like a good idea to the patient. It's always a bad idea as far as we're concerned because it never needs to be stopped in those situations.

It's being stopped by someone who knows nothing about the medicine or at best gets their education from the television about that medicine. There, again, if it's the other physician that did this, there's only one remedy, and it does take a little bit of your effort, and that is either write a note to that doctor or give him a call. Doctor Schmo, doctor Cush here, mister Smith says you stopped his methotrexate. Is that true? Why would you do that?

And, you know, then they're, like, double talking and hemming and hawing and say, oh, he misunderstood. And but you know what? Doctor Smith this is doctor Schmo, excuse me, is never gonna do that again. Lastly, external forces. Insurance companies, you know, bad deliveries, pharmacy issues, refill issues, dog ate my homework, again, beyond the patient's control, and they never restarted the medicine.

And there the answer is real simple. It's like the first scenario. This thing called the phone. If things are not going well with regard to medicine, call my office and I'll fix it. I think the bottom line is that, you know, bailing out on a DMARD is not always a bad thing.

Sometimes it's a good thing. The patient can be managed with less medicine. This way you're not contributing to polypharmacy, which is a gigantic problem in many of our patients, especially as they get older, especially as they get more complex. I think that it's really about negotiating. It's about setting expectations with patients and letting them to know that they can call you to find out what to do when considering stopping a medicine.

That's it for the DMARD bailout. Again, you give us two hours, we'll give you the ACR meeting virtually. We have a lot of interesting plans. It's all about, ways that you can engage and learn and get perspectives on the data and new studies being presented. These are the things we'll be highlighting, at RheumNow come November for the virtual ACR meeting.

We'll see you then. Take care.