QD 74 - Weighty Decisions In RA Save
QD Clinic - Lessons from the clinic
Weighing Decisions on Drug D/C, Weaning, Add-ons, etc
Features Dr. Jack Cush
YouTube link: https://youtu.be/aj3_t2yxbbU
Transcription
This is QD clinic brought to you by RheumNow live. I'm doctor Jack Cush from rheumnow.com. Today, we're gonna talk about weighing decisions in rheumatoid arthritis. We did this today in clinic, we sort of said, what do you do? This or that?
Here's some examples. Drug one versus drug two. We don't really need two drugs. Which one do we stop? How do you make that decision?
Usually this is in the context of being on multiple DMARDs and trying to stop one. It could be on the other hand, which analgesic to stop, or it could be prednisone versus nonsteroidals. But let's just say this is two DMARDs, conventional DMARDs, biologic DMARDs, it doesn't really matter. The decision is really quite simple. Number one, ask the patient which drug do you want to go off of?
And this is of course assuming that you can go off of therapy and cone down to what is needed. Meaning the patient's doing well in remission, has no swollen joints. But ask the patient, which drug would you like to stay on, which drug would you like to go off? That drives the boat, at least as far as I'm concerned. The next rung as far as treatment decisions might be cost, and that's cost to patient or cost to society.
Third might be complexity of therapy. Go with the easier regimen. Patients are already having a hard enough time keeping up with all your prescriptions and all the things that you want them to do. And then lastly, polypharmacy, the drug that's going to take them out of polypharmacy and into some sort of simple regimen. So ask the patient, keep it simple, stupid.
Kiss. Second issue, do I wean the biologic DMARD or the DMARD or do I discontinue? What should I do? Well, here it's a different decision. It's actually quite simple.
You spend most of your life trying to control rheumatoid arthritis, a deadly, dastardly, progressive, never ending condition, and yet someone wants to take monotherapy, less therapy, it ain't that simple. So, one, you should discourage people who want to go off of therapy when they're doing great. Now that is assuming they've shown you active synovitis and clear cut evidence of rheumatoid arthritis. The odds of people going to drug free remission off of therapy are very low, ten percent. So do you wean or just do you discontinue when they're doing great?
Well, ACR guidelines on this were actually quite intelligent, and I think the best out there. They say that if you're in LDAS, low disease activity state, you don't change nothing. The only way you can change is if you're in remission. EULAR guidelines, as we reviewed last week, said that if you're in deep remission, sustained remission, then you can consider changing the interval and taking less drug as opposed to going off of it. And then if you're on two drugs, you know, EULAR said you should go off of the biologic or targeted synthetic DMARD first because if you do go off and they flare, you can recapture response in eighty percent of patients.
However, if you stop the DMARD, which is what I prefer to do, chances of recapture is less. It might be only fifty percent. But staying on the biologic keeps the patient out of FLAIR, in my opinion, and, actually preserves radiographic, integrity, meaning they're less likely to progress. Do you increase therapy or add on therapy? Someone is on methotrexate, or a monotherapy DMARDs and they're not doing well.
Do you swap it out because that drug wasn't working, or you just add on top of it? The bottom line if this is that if it was methotrexate, you add on top of it, keep them on methotrexate unless they do not tolerate it. If they do not tolerate it, then you can either go to monotherapy, but really you're gonna need two drugs. So you need another DMARDs like leflunomide, and then you add on top of that either other conventional DMARDs or a tar targeted synthetic or, another MOA non TNF or TNF. And then lastly, what do you do like this when the patient's got a lot of complaints but they got nothing to show for it?
Meaning they have no synovitis and their sed rate and CRP are normal and you don't suspect that synovitis and inflammation are out of control, but yet they're not under control. Number one, analgesics. Most patients tend to under dose their analgesics, go with safe agents. Number two, modify lifestyle. And number three, fix their sleep and identify fibromyalgia and tell them they're doing great.
Because when they know they're doing great maybe they won't worry so much. Speaking of worry so much, if you went to RoomNow live, your life would be great. Let me tell you about our very first session, pod one, Rheumatoid Arthritis. Management of Infections in TB by Kevin Winthrop from Oregon. He is the master of disaster.
Your disaster is being infectious. Kevin's got the answers. Fabulous speaker. Followed up by Roy Fleishman, who is encyclopedic, as far as his knowledge of new therapies and drugs that are just now new on the market. He's He the guy that does all the trials.
He's the first author on all the major drugs. Hear what he has to say. And then John Giles from Columbia in New York is gonna give the best lecture you've ever heard on cardiovascular risk assessment and prevention. That's just the first session of many sessions. Room now live.
Register now. There's still a few seats. Talk to you tomorrow on QD clinic.
Here's some examples. Drug one versus drug two. We don't really need two drugs. Which one do we stop? How do you make that decision?
Usually this is in the context of being on multiple DMARDs and trying to stop one. It could be on the other hand, which analgesic to stop, or it could be prednisone versus nonsteroidals. But let's just say this is two DMARDs, conventional DMARDs, biologic DMARDs, it doesn't really matter. The decision is really quite simple. Number one, ask the patient which drug do you want to go off of?
And this is of course assuming that you can go off of therapy and cone down to what is needed. Meaning the patient's doing well in remission, has no swollen joints. But ask the patient, which drug would you like to stay on, which drug would you like to go off? That drives the boat, at least as far as I'm concerned. The next rung as far as treatment decisions might be cost, and that's cost to patient or cost to society.
Third might be complexity of therapy. Go with the easier regimen. Patients are already having a hard enough time keeping up with all your prescriptions and all the things that you want them to do. And then lastly, polypharmacy, the drug that's going to take them out of polypharmacy and into some sort of simple regimen. So ask the patient, keep it simple, stupid.
Kiss. Second issue, do I wean the biologic DMARD or the DMARD or do I discontinue? What should I do? Well, here it's a different decision. It's actually quite simple.
You spend most of your life trying to control rheumatoid arthritis, a deadly, dastardly, progressive, never ending condition, and yet someone wants to take monotherapy, less therapy, it ain't that simple. So, one, you should discourage people who want to go off of therapy when they're doing great. Now that is assuming they've shown you active synovitis and clear cut evidence of rheumatoid arthritis. The odds of people going to drug free remission off of therapy are very low, ten percent. So do you wean or just do you discontinue when they're doing great?
Well, ACR guidelines on this were actually quite intelligent, and I think the best out there. They say that if you're in LDAS, low disease activity state, you don't change nothing. The only way you can change is if you're in remission. EULAR guidelines, as we reviewed last week, said that if you're in deep remission, sustained remission, then you can consider changing the interval and taking less drug as opposed to going off of it. And then if you're on two drugs, you know, EULAR said you should go off of the biologic or targeted synthetic DMARD first because if you do go off and they flare, you can recapture response in eighty percent of patients.
However, if you stop the DMARD, which is what I prefer to do, chances of recapture is less. It might be only fifty percent. But staying on the biologic keeps the patient out of FLAIR, in my opinion, and, actually preserves radiographic, integrity, meaning they're less likely to progress. Do you increase therapy or add on therapy? Someone is on methotrexate, or a monotherapy DMARDs and they're not doing well.
Do you swap it out because that drug wasn't working, or you just add on top of it? The bottom line if this is that if it was methotrexate, you add on top of it, keep them on methotrexate unless they do not tolerate it. If they do not tolerate it, then you can either go to monotherapy, but really you're gonna need two drugs. So you need another DMARDs like leflunomide, and then you add on top of that either other conventional DMARDs or a tar targeted synthetic or, another MOA non TNF or TNF. And then lastly, what do you do like this when the patient's got a lot of complaints but they got nothing to show for it?
Meaning they have no synovitis and their sed rate and CRP are normal and you don't suspect that synovitis and inflammation are out of control, but yet they're not under control. Number one, analgesics. Most patients tend to under dose their analgesics, go with safe agents. Number two, modify lifestyle. And number three, fix their sleep and identify fibromyalgia and tell them they're doing great.
Because when they know they're doing great maybe they won't worry so much. Speaking of worry so much, if you went to RoomNow live, your life would be great. Let me tell you about our very first session, pod one, Rheumatoid Arthritis. Management of Infections in TB by Kevin Winthrop from Oregon. He is the master of disaster.
Your disaster is being infectious. Kevin's got the answers. Fabulous speaker. Followed up by Roy Fleishman, who is encyclopedic, as far as his knowledge of new therapies and drugs that are just now new on the market. He's He the guy that does all the trials.
He's the first author on all the major drugs. Hear what he has to say. And then John Giles from Columbia in New York is gonna give the best lecture you've ever heard on cardiovascular risk assessment and prevention. That's just the first session of many sessions. Room now live.
Register now. There's still a few seats. Talk to you tomorrow on QD clinic.
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