QD 65 - EULAR RA Guidelines, Part 1 Save
QD Clinic - Lessons from the clinic and literature
Part 1 of a review of the 2020 EULAR Recommendations for the Management of Rheumatoid Arthritis
Features Dr Jack Cush
Transcription
This is QD Clinic. I'm doctor Jack Cush, executive editor of rheumnow.com. QD Clinic is brought to you by RheumNow live, March 13 through the fifteenth in Fort Worth. In the next few QD clinics, we're gonna discuss the new EULAR twenty twenty guidelines for the management of rheumatoid arthritis using synthetic and biologic agents. You can download this on the Annals of Rheumatic Disease website.
It's a full read. And I kinda discussed this a little bit last week, but I thought in, you know, reviewing this that there's a lot of detail here, and I think it's worth going over in a few successive videos. So on our first part, we're gonna discuss the overarching principles, how the guidelines were, formulated, and and then in subsequent videos, we'll discuss the 12 specific recommendations and then end up with a discussion about where these guidelines are strong and where they are not. So to begin with, this is a current publication. It's in play.
It's got many authors, most of whom are worldwide and mostly centered in The EU. But there is one US author, Ken Saag, representing our interest, here. It's a very impressive group led by Joseph Small and Robert Landway, and Johannes Bilsma, and others. They basically reviewed the history of EULAR guidelines, which started out in 2010 for the management RA and were updated in 2016. Along the way, you the ACR and EULAR have collaborated on developing classification criteria and also remission criteria.
And while their last recommendations were in 2016, they felt that the, advent of new therapies and new data warranted an update in the twenty twenty recommendations, which have again just been published. As you know, with EULA recommendations, there's always an overarching principles, things to keep in mind, the general approach to the disease or that which is being, promulgated, and then specific recommendations. They have five overarching principles that they, put forth. The first, it's not number one, it's A. It says treatment of patients with RA should aim at the best care and must be based on a shared decision between the patient and rheumatologist.
So best care makes sense. Shared decision making is something that they've always been in favor of and they believe this is important to get patient buy in, to, improve adherence, and to foster a healthy physician patient relationship. Inherent in this is a few things. Number one, patient education. This includes an ongoing need for patient education.
If not you, then who in your team will do this? This needs to be addressed. This is vitally important. Patients don't believe in their therapy, they're not gonna use that therapy. And second is the need for communication skills.
You need to be good at communicating RA and its therapy and what it is that you wanna do, and then have that supplemented by others in your team that will help with education. The second principle B is that treatment decisions are based on disease activity, safety issues, and other patient factors such as comorbidities and progression of structural damage. So, they're saying here that, you know, right from the outset, you need to consider all these factors when choosing a therapy, meaning there's not one drug that works for all patients, although insurance seems to think so, that you really need to consider how severe the patient is, and what other factors are in play. Patient preferences and patient you know, who come in asking for a specific drug are more likely to respond to that drug than the drug they've never heard of that you're gonna prescribe for them. So their decisions and their wishes probably are very important here.
Comorbidities, we know will color the therapies we use because they will restrict some of the things that we can use and some that we can't use, And that when we get into successive drug failures, comorbidities become a much larger component in choosing therapy, such that you may not have your best or your second best choice. It may be something you have to back into what I call defensive prescribing. So, again, structural damage is also another big issue. You know, so I think all of our drugs, that are on the list here from the biologic to the synthetics really are capable of halting progression, but, you know, you may have a particular view on which does that best. So, factors are important.
Think for instance about the patient who has a history of herpes zoster or may be at risk for herpes zoster, That people in Southeast Asia are much more greater risk of getting zoster. Same thing for venous thromboembolic events, you may not want to use a JAK inhibitor in someone who recently had a PE or DVT related to their RA. The third principle is that rheumatologists should be primarily responsible for the care of the RA patient. This includes the room specialist nurse, the PA or nurse practitioner that works with the rheumatologist, and also then the multidisciplinary group that is led by the rheumatologist. The, it's obvious here why the rheumatologist should be at the top of the pyramid when it comes to guiding and treating the patient who has new and problematic rheumatoid arthritis.
The fifth, the fourth, entry, D, is that you need access to multiple drugs with different mechanisms of action to address the heterogeneity of RA both from the outset of management and then over the life course of that drug. There are a lot of factors in here, you know, may not always respond to a TNF inhibitor forced upon you by insurance companies, but there may be others that you can't use methotrexate in. So, again, there are things that you can't use from the outset that you'll need choices for. There are choices that you'll need when you have an initial loss of therapy or primary lack of efficacy. And then you have it as an issue of patients who are going to lose efficacy over time.
And then lastly, you need multiple drugs to manage this disease over its length, which is gonna be lifelong in almost ninety percent of patients. And the last, principle e, RA incurs a very high medical and societal cost, all of which should be considered in its management by the treating rheumatologist because you need to address this issue with the payers. You know, the stakeholders that are involved here are numerous, and again, we have to be able to address the issue of, you know, the benefits of one versus the cost of another, meaning that what's the cost of not treating this disease aggressively when it needs aggressive treatment. Well, later down the line, there's gonna be incredible cost with regard to surgery, hospital hospitalizations, and complications. So that's it for this edition, the first edition, overarching principles, regarding the EULAR management recommendations.
Tune in for more tomorrow. Oh, come to RheumNow live. Hang out with Artie Cavanaugh, Jack Cush, Joel Kremember, Alvin Wells, Roy Fleishman, and a ton of other interesting faculty who will also be at the meeting.
It's a full read. And I kinda discussed this a little bit last week, but I thought in, you know, reviewing this that there's a lot of detail here, and I think it's worth going over in a few successive videos. So on our first part, we're gonna discuss the overarching principles, how the guidelines were, formulated, and and then in subsequent videos, we'll discuss the 12 specific recommendations and then end up with a discussion about where these guidelines are strong and where they are not. So to begin with, this is a current publication. It's in play.
It's got many authors, most of whom are worldwide and mostly centered in The EU. But there is one US author, Ken Saag, representing our interest, here. It's a very impressive group led by Joseph Small and Robert Landway, and Johannes Bilsma, and others. They basically reviewed the history of EULAR guidelines, which started out in 2010 for the management RA and were updated in 2016. Along the way, you the ACR and EULAR have collaborated on developing classification criteria and also remission criteria.
And while their last recommendations were in 2016, they felt that the, advent of new therapies and new data warranted an update in the twenty twenty recommendations, which have again just been published. As you know, with EULA recommendations, there's always an overarching principles, things to keep in mind, the general approach to the disease or that which is being, promulgated, and then specific recommendations. They have five overarching principles that they, put forth. The first, it's not number one, it's A. It says treatment of patients with RA should aim at the best care and must be based on a shared decision between the patient and rheumatologist.
So best care makes sense. Shared decision making is something that they've always been in favor of and they believe this is important to get patient buy in, to, improve adherence, and to foster a healthy physician patient relationship. Inherent in this is a few things. Number one, patient education. This includes an ongoing need for patient education.
If not you, then who in your team will do this? This needs to be addressed. This is vitally important. Patients don't believe in their therapy, they're not gonna use that therapy. And second is the need for communication skills.
You need to be good at communicating RA and its therapy and what it is that you wanna do, and then have that supplemented by others in your team that will help with education. The second principle B is that treatment decisions are based on disease activity, safety issues, and other patient factors such as comorbidities and progression of structural damage. So, they're saying here that, you know, right from the outset, you need to consider all these factors when choosing a therapy, meaning there's not one drug that works for all patients, although insurance seems to think so, that you really need to consider how severe the patient is, and what other factors are in play. Patient preferences and patient you know, who come in asking for a specific drug are more likely to respond to that drug than the drug they've never heard of that you're gonna prescribe for them. So their decisions and their wishes probably are very important here.
Comorbidities, we know will color the therapies we use because they will restrict some of the things that we can use and some that we can't use, And that when we get into successive drug failures, comorbidities become a much larger component in choosing therapy, such that you may not have your best or your second best choice. It may be something you have to back into what I call defensive prescribing. So, again, structural damage is also another big issue. You know, so I think all of our drugs, that are on the list here from the biologic to the synthetics really are capable of halting progression, but, you know, you may have a particular view on which does that best. So, factors are important.
Think for instance about the patient who has a history of herpes zoster or may be at risk for herpes zoster, That people in Southeast Asia are much more greater risk of getting zoster. Same thing for venous thromboembolic events, you may not want to use a JAK inhibitor in someone who recently had a PE or DVT related to their RA. The third principle is that rheumatologists should be primarily responsible for the care of the RA patient. This includes the room specialist nurse, the PA or nurse practitioner that works with the rheumatologist, and also then the multidisciplinary group that is led by the rheumatologist. The, it's obvious here why the rheumatologist should be at the top of the pyramid when it comes to guiding and treating the patient who has new and problematic rheumatoid arthritis.
The fifth, the fourth, entry, D, is that you need access to multiple drugs with different mechanisms of action to address the heterogeneity of RA both from the outset of management and then over the life course of that drug. There are a lot of factors in here, you know, may not always respond to a TNF inhibitor forced upon you by insurance companies, but there may be others that you can't use methotrexate in. So, again, there are things that you can't use from the outset that you'll need choices for. There are choices that you'll need when you have an initial loss of therapy or primary lack of efficacy. And then you have it as an issue of patients who are going to lose efficacy over time.
And then lastly, you need multiple drugs to manage this disease over its length, which is gonna be lifelong in almost ninety percent of patients. And the last, principle e, RA incurs a very high medical and societal cost, all of which should be considered in its management by the treating rheumatologist because you need to address this issue with the payers. You know, the stakeholders that are involved here are numerous, and again, we have to be able to address the issue of, you know, the benefits of one versus the cost of another, meaning that what's the cost of not treating this disease aggressively when it needs aggressive treatment. Well, later down the line, there's gonna be incredible cost with regard to surgery, hospital hospitalizations, and complications. So that's it for this edition, the first edition, overarching principles, regarding the EULAR management recommendations.
Tune in for more tomorrow. Oh, come to RheumNow live. Hang out with Artie Cavanaugh, Jack Cush, Joel Kremember, Alvin Wells, Roy Fleishman, and a ton of other interesting faculty who will also be at the meeting.
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