QD 83 - 7 DMARDs And Counting Save

This is QD Clinic. I'm Jack Cush from roomnow.com. QD Clinic is brought to you by roomnow.live. So this case is called seven DMARDs and counting. A CCP positive rheumatoid arthritis patient comes to you with many swollen and tender joints, 11 tender, nine swollen, a C.

I. Of 32, it's the same as rapid, same as a gas. The patient had previously been treated with methotrexate, etanercept, adalimumab, abatacib, baricitinib, tofacitinib, Kevzara, otezla, primalast. Right now the patient's on a primalast, sarilumab and ten milligrams of prednisone is doing poor. Why is the patient on Tesla?

Someone thought the patient might have psoriatic arthritis. This is a strongly c c CCP positive individual. And the question is, what would you do next? This patient had been doing really, really well for a long time on methotrexate and etanercept, like seven, eight, nine years, and then boom, out of nowhere, a secondary loss of response. So this is like seven or eight DMARDs in, and what are you going to do next?

What is your next choice? What do you offer the patient? Here are the offerings, but and we have to go with drugs that patient hasn't seen yet. How about sulfasalazine with Anakinra? Number one.

How about number two, leflunomide plus rituximab? Number three, methotrexate plus cerdulizumab? Four, triple DMAR therapy? Five, some other concoction that only you are known for? Well, the good news is we've put this out to a Twitter poll and we asked rheumatologists on Twitter, got back 231 responses in twenty four hours, and the number one answer by seventy eight percent of your peers was, that's right, number two, leflinamide plus rituximab.

What do you think was second most common? Methotrexate plus cerdulizumab at eleven percent. So that locks up eighty nine percent of the choices. Only eight percent would do a d triple DMARD and only two point six percent have any faith in anakinra. By the anakinra is FDA approved and works in forty percent of people the same way etanercept works.

But nonetheless, all of you think it's not a good drug, but it is a good drug. It just happens to have happens to require to be given, once daily. So what's the wrap on Rituximab? You put it last on your list because you've got so many other choices, but realize there's a lot of data about rituximab working great as the second biologic. There's a lot of data about rituximab working great as the first biologic.

To put any biologic ninth in the list really means that you're stacking the odds against it, right? I mean, so someone who fails multiple biologics is gonna continue to fail future biologics or future therapies because there's probably much more involved here than a unique biology that you haven't quite, hit upon yet. So, my point is don't wait until the ninth biologic or the ninth DMAR to use rituximab. I think it merits a consideration soon after you fail a TNF inhibitor or maybe right after they fail methotrexate. Of course, everybody's afraid of a one in thirty thousand risk of PML, which again, that's like chance of getting hit by lightning or getting, married to a donkey.

You know, I don't know that either of those are possible or even legal. So, this case is a tough case. We'll see what happens when the patient comes back on her next combination of therapy, but if you chose rituximab plus leflinamide, you're falling in line with over eighty percent of your peers. That's it for this edition. Go to roomnow.live to register.