QD 66 - Part 2, EULAR RA Treatment Guidelines Save

This is QD Clinic, and I'm doctor Jack Cush from RheumNow. QD Clinic is brought to you by RheumNow Live, the little big meeting. Little because you'll be one of a 150 people in the room rubbing elbows with the faculty. It's not like those gigantic meetings where there's 600 people or 15,000 people and you get lost and don't know what to see or do. It's a big meeting because you'll be with big time faculty and have some big time opportunities to exchange meaningfully with them.

Also, it's gonna be big and that's gonna be streamed over the Internet to a larger audience. This week, we're discussing the EULAR guidelines or recommendations for the treatment and management of rheumatoid arthritis. Yesterday, we went over the overarching principles, and today we're gonna start with the 12 recommendations and cover the first three. So number one begins with therapy with debar and should be started as soon as the diagnosis of rheumatoid arthritis is made. This is sort of a no brainer, but yet there still are a lot of patients who have the diagnosis of RA or are entertaining a diagnosis of RA in whom symptomatic disease management is occurring.

If I make a diagnosis of rheumatoid arthritis or have a strong suspicion and I'm going to order confirmatory labs, the patient leaves the prescription, leaves the office with a prescription for methotrexate or another real DMARD, and that may be tailored up to maybe multiple therapies. Again, you can always stop them at any point. The gravest mistake in managing RA is to not be aggressive, not diagnose early, not institute treatment early. I kinda like my EMR for the one simple fact that if I have a diagnosed with RA and the patient isn't on a DMARD, my EMR is asking me why is the patient not on a DMARD. And I think that that sort of makes sense.

You don't wait, you don't sort of wishy wash about, well, let me just see how they respond to nonsteroidals or low dose prednisone or let me use some hydroxychloroquine because I really can't make up my mind here about whether this is or isn't rheumatoid arthritis. Either you're in or you're out. Either symptomatically manage it and call it undiagnosed inflammatory arthritis. But once you put a label of RA, m o five dot seven nine or MO6.1 or O9 for seronegative, you need to start DMARN therapy. Again, to not, to have RA and not be on a DMARD is to not have RA.

Recommendation number two, treatment should be aimed at reaching a target of sustained remission or a low disease activity state in every patient. This is a carryover from the twenty sixteen recommendations. It makes a great deal of sense. I think you want obviously to have a T to t attitude. Treat to target is strongly advocated in, by EULAR.

They have recommendations on on treat to target and its benefits. I think that it doesn't matter what target you're going to use or what tool you're going to use. You need to use the tool and treat to that tool. So, again, ACR guidelines with EULAR, I think, said that C dye is preferable, but it could be S dye. It could be rapid three.

I use a gas score, which is patient pain, HAC score, and, their pain level, pain, HAC score, and tender joint count. It actually turns out to perform just as well as the CDAI score, which is probably the best correlated with the dash 28 ESR. Nonetheless, it doesn't matter which one you use. A goal of in the case of CDAI or gas of LDAS, load is activity state of seven or less or remission of three or less is what you need to have. If you don't get there, then you need to move on.

The question here are the time frames. The time frames are actually, critical. They say here that if you're not getting there let's see now. If you're not getting there within that's the next guideline. So, again, use the the these treatment guidelines to get the best response.

Use the tools that you have, these validated tools on assessment to achieve your target. Now, should be going for remission, but sometimes a low disease activity state is prudent, and that would be patients who already have damage, where because of their damage, because of secondary degenerative change or periarticular disease, you may not get to a very low score, but you may get to a low enough score to indicate that they're in a low disease activity state. The third and last one we'll consider today is monitoring should be frequent in active disease, meaning every one to three months. If there is no improvement by month three, after the start of treatment, you need to be changing your treatment. Or if you don't achieve your target, let's say a C.

Dye of less than three, by six months, treatment should be changed, adjusted, whatever you need to achieve your goals. So they're putting a twelve week limit on the attainment of improvement, and they define improvement as at least 50% improvement in TJC and SJC. I think these are a little too lax. I think with many of the drugs we have now, you should be getting better in two weeks or four weeks. So and I would say six weeks is really where you need to make be making changes, but that's the the that's the Jack Cush recommendation on management, not the UR recommendation.

They do go on to point out that rapid attainment of a selected target endpoint is now regarded as being the most critical of of sensibilities you need to employ here. There is evidence that says that if you don't achieve this, rapidly, that if you don't achieve at least a 50% reduction within three months, the probabil probability of reaching the treatment goal of remission is low. So you do need a rapid response. Rapid responders are people who gonna have fantastic responses to the drug you're using. If you're getting a so so slow response, takes twelve weeks, sixteen weeks, maybe twenty four weeks to get to the goal, well, how good is that therapy gonna be in the long run?

Again, I think you really need to think about that. These guidelines are being laid out in sequence, in accord with the idea of starting out with someone with early RA and new changes to therapy. It conforms the algorithm that they use and is on the website and in the paper. That's it for episode number two of UR recommendations regarding the management of rheumatoid arthritis.