When It Comes to RA, Hit It Hard and Early : Drug combinations should be used, since the 'data show we undertreat' RA.

SANTA MONICA, CALIF. — The treatment of rheumatoid arthritis has undergone a sea change, word of which has not reached beyond rheumatology in many cases.

Primary among the new rules of RA care is the admonition to use the best drug first and that “overtreatment” is good. Physicians should move more quickly to using combinations of agents, because the “data show we undertreat,” said Dr. John J. Cush, director of clinical rheumatology for the Baylor Research Institute and professor of medicine and rheumatology at Baylor University Medical Center at Dallas.

In addition to the aggressive use of disease-modifying antirheumatic drugs (DMARDs), optimal treatment of RA requires that physicians seize the opportunity to diagnose and manage cases of early disease. Many measures can be adopted to help achieve this goal, but Dr. Cush advocates the “promotion of practice policies to facilitate referral and [ensure] that every patient seeking an appointment for joint pain should be seen within 2 weeks or sooner.”

The integration of disease activity metrics can enhance outcomes by guiding treatment changes to achieve a specific goal. “Use of metrics yields a fourfold increase in remission rates,” Dr. Cush said at a meeting sponsored by

Word of the negative impact of comorbidities in RA has not spread far beyond rheumatology to primary care specialties. Given the cardiovascular disease (CVD) risks alone, physicians need to treat comorbidities in this population, he said.

RA patients develop CVD 10 years earlier than their unaffected peers, they have twice the malignancy rate of the general population, their rate of serious infection is six to nine times that of the general population, and their risk for both pulmonary disease and gastrointestinal bleeding is elevated. As a result, the life expectancy of RA patients is shorter than that of their age-matched peers (10 years shorter for women and 4 years shorter for men).

Data from the Mayo Clinic in Rochester, Minn., show that survival has improved significantly over the past decade. Research presented at the 2009 annual meeting of the American College of Rheumatology, but not yet published, indicated that survival was 70.7% among 147 RA patients who were followed in 1955–1994. In 1995–2007, survival increased to 79.5% in a group of 463 RA patients. Both patient groups were from the Olmsted County, Minn., cohort.

Earlier diagnosis and the use of methotrexate and biologic DMARDs may have contributed to this finding, Dr. Cush said.

Although many rheumatologists are enamored with the potential benefits of new biologics, they should remain resolute in their use of methotrexate, according to Dr. Cush. Findings from a recent meta-analysis suggest that the optimal methotrexate dosage may be achieved by starting at 15 mg/week orally, then escalating by 5 mg/month to a maximum dosage of 25–30 mg/week or the highest tolerable dose. In cases of insufficient response, the route of administration can be switched from oral to subcutaneous administration (Ann. Rheum. Dis. 2009;68:1094–9).

Several studies have compared methotrexate vs. tumor necrosis factor inhibitors with regard to efficacy and x-ray–protective effects. Methotrexate appears to be as potent as TNF inhibitors in terms of clinical outcomes. When x-ray outcomes are analyzed, however, the biologic has a margin of benefit over methotrexate that becomes more pronounced when the TNF inhibitor is combined with methotrexate.

Other data have documented the cost-effectiveness of therapy in early RA. Very early DMARD therapy is cost effective in reducing RA progression, but the cost-effectiveness of early biologics remains uncertain (Ann. Intern. Med. 2009;151:612–21).

If methotrexate monotherapy does not produce enough benefit, the recommended course is to add a biologic DMARD, usually a TNF inhibitor. The top five indications for the use of a TNF blocker in rheumatology are failure of methotrexate monotherapy, failure of multiple DMARDs, physician assessment of activity, presence of erosions on x-rays, and functional disability.

There is room for improvement in the treatment of RA. Remission is not common, Dr. Cush noted.

Disclosures: Dr. Cush reported being a clinical adviser, investigator, or consultant for numerous pharmaceutical companies. SDEF, Rheumatology News, and this newspaper are owned by Elsevier.

There continues to be room for improvement in rheumatoid arthritis therapy. Remission is not common.

Source DR. CUSH

SANTA MONICA, CALIF. — The treatment of rheumatoid arthritis has undergone a sea change, word of which has not reached beyond rheumatology in many cases.

Primary among the new rules of RA care is the admonition to use the best drug first and that “overtreatment” is good. Physicians should move more quickly to using combinations of agents, because the “data show we undertreat,” said Dr. John J. Cush, director of clinical rheumatology for the Baylor Research Institute and professor of medicine and rheumatology at Baylor University Medical Center at Dallas.

In addition to the aggressive use of disease-modifying antirheumatic drugs (DMARDs), optimal treatment of RA requires that physicians seize the opportunity to diagnose and manage cases of early disease. Many measures can be adopted to help achieve this goal, but Dr. Cush advocates the “promotion of practice policies to facilitate referral and [ensure] that every patient seeking an appointment for joint pain should be seen within 2 weeks or sooner.”

The integration of disease activity metrics can enhance outcomes by guiding treatment changes to achieve a specific goal. “Use of metrics yields a fourfold increase in remission rates,” Dr. Cush said at a meeting sponsored by

Word of the negative impact of comorbidities in RA has not spread far beyond rheumatology to primary care specialties. Given the cardiovascular disease (CVD) risks alone, physicians need to treat comorbidities in this population, he said.

RA patients develop CVD 10 years earlier than their unaffected peers, they have twice the malignancy rate of the general population, their rate of serious infection is six to nine times that of the general population, and their risk for both pulmonary disease and gastrointestinal bleeding is elevated. As a result, the life expectancy of RA patients is shorter than that of their age-matched peers (10 years shorter for women and 4 years shorter for men).

Data from the Mayo Clinic in Rochester, Minn., show that survival has improved significantly over the past decade. Research presented at the 2009 annual meeting of the American College of Rheumatology, but not yet published, indicated that survival was 70.7% among 147 RA patients who were followed in 1955–1994. In 1995–2007, survival increased to 79.5% in a group of 463 RA patients. Both patient groups were from the Olmsted County, Minn., cohort.

Earlier diagnosis and the use of methotrexate and biologic DMARDs may have contributed to this finding, Dr. Cush said.

Although many rheumatologists are enamored with the potential benefits of new biologics, they should remain resolute in their use of methotrexate, according to Dr. Cush. Findings from a recent meta-analysis suggest that the optimal methotrexate dosage may be achieved by starting at 15 mg/week orally, then escalating by 5 mg/month to a maximum dosage of 25–30 mg/week or the highest tolerable dose. In cases of insufficient response, the route of administration can be switched from oral to subcutaneous administration (Ann. Rheum. Dis. 2009;68:1094–9).

Several studies have compared methotrexate vs. tumor necrosis factor inhibitors with regard to efficacy and x-ray–protective effects. Methotrexate appears to be as potent as TNF inhibitors in terms of clinical outcomes. When x-ray outcomes are analyzed, however, the biologic has a margin of benefit over methotrexate that becomes more pronounced when the TNF inhibitor is combined with methotrexate.

Other data have documented the cost-effectiveness of therapy in early RA. Very early DMARD therapy is cost effective in reducing RA progression, but the cost-effectiveness of early biologics remains uncertain (Ann. Intern. Med. 2009;151:612–21).

If methotrexate monotherapy does not produce enough benefit, the recommended course is to add a biologic DMARD, usually a TNF inhibitor. The top five indications for the use of a TNF blocker in rheumatology are failure of methotrexate monotherapy, failure of multiple DMARDs, physician assessment of activity, presence of erosions on x-rays, and functional disability.

There is room for improvement in the treatment of RA. Remission is not common, Dr. Cush noted.

Disclosures: Dr. Cush reported being a clinical adviser, investigator, or consultant for numerous pharmaceutical companies. SDEF, Rheumatology News, and this newspaper are owned by Elsevier.

There continues to be room for improvement in rheumatoid arthritis therapy. Remission is not common.

Source DR. CUSH

SANTA MONICA, CALIF. — The treatment of rheumatoid arthritis has undergone a sea change, word of which has not reached beyond rheumatology in many cases.

Primary among the new rules of RA care is the admonition to use the best drug first and that “overtreatment” is good. Physicians should move more quickly to using combinations of agents, because the “data show we undertreat,” said Dr. John J. Cush, director of clinical rheumatology for the Baylor Research Institute and professor of medicine and rheumatology at Baylor University Medical Center at Dallas.

In addition to the aggressive use of disease-modifying antirheumatic drugs (DMARDs), optimal treatment of RA requires that physicians seize the opportunity to diagnose and manage cases of early disease. Many measures can be adopted to help achieve this goal, but Dr. Cush advocates the “promotion of practice policies to facilitate referral and [ensure] that every patient seeking an appointment for joint pain should be seen within 2 weeks or sooner.”

The integration of disease activity metrics can enhance outcomes by guiding treatment changes to achieve a specific goal. “Use of metrics yields a fourfold increase in remission rates,” Dr. Cush said at a meeting sponsored by

Word of the negative impact of comorbidities in RA has not spread far beyond rheumatology to primary care specialties. Given the cardiovascular disease (CVD) risks alone, physicians need to treat comorbidities in this population, he said.

RA patients develop CVD 10 years earlier than their unaffected peers, they have twice the malignancy rate of the general population, their rate of serious infection is six to nine times that of the general population, and their risk for both pulmonary disease and gastrointestinal bleeding is elevated. As a result, the life expectancy of RA patients is shorter than that of their age-matched peers (10 years shorter for women and 4 years shorter for men).

Data from the Mayo Clinic in Rochester, Minn., show that survival has improved significantly over the past decade. Research presented at the 2009 annual meeting of the American College of Rheumatology, but not yet published, indicated that survival was 70.7% among 147 RA patients who were followed in 1955–1994. In 1995–2007, survival increased to 79.5% in a group of 463 RA patients. Both patient groups were from the Olmsted County, Minn., cohort.

Earlier diagnosis and the use of methotrexate and biologic DMARDs may have contributed to this finding, Dr. Cush said.

Although many rheumatologists are enamored with the potential benefits of new biologics, they should remain resolute in their use of methotrexate, according to Dr. Cush. Findings from a recent meta-analysis suggest that the optimal methotrexate dosage may be achieved by starting at 15 mg/week orally, then escalating by 5 mg/month to a maximum dosage of 25–30 mg/week or the highest tolerable dose. In cases of insufficient response, the route of administration can be switched from oral to subcutaneous administration (Ann. Rheum. Dis. 2009;68:1094–9).

Several studies have compared methotrexate vs. tumor necrosis factor inhibitors with regard to efficacy and x-ray–protective effects. Methotrexate appears to be as potent as TNF inhibitors in terms of clinical outcomes. When x-ray outcomes are analyzed, however, the biologic has a margin of benefit over methotrexate that becomes more pronounced when the TNF inhibitor is combined with methotrexate.

Other data have documented the cost-effectiveness of therapy in early RA. Very early DMARD therapy is cost effective in reducing RA progression, but the cost-effectiveness of early biologics remains uncertain (Ann. Intern. Med. 2009;151:612–21).

If methotrexate monotherapy does not produce enough benefit, the recommended course is to add a biologic DMARD, usually a TNF inhibitor. The top five indications for the use of a TNF blocker in rheumatology are failure of methotrexate monotherapy, failure of multiple DMARDs, physician assessment of activity, presence of erosions on x-rays, and functional disability.

There is room for improvement in the treatment of RA. Remission is not common, Dr. Cush noted.

Disclosures: Dr. Cush reported being a clinical adviser, investigator, or consultant for numerous pharmaceutical companies. SDEF, Rheumatology News, and this newspaper are owned by Elsevier.

There continues to be room for improvement in rheumatoid arthritis therapy. Remission is not common.

Source DR. CUSH