PRD 2011

All health care is local, as the late Speaker of the House Tip O’Neill so famously noted about politics. And politics is at least part of the reason why we physicians face the challenges we do in health care reform.

The Affordable Care Act takes a broad approach to health care reform, rather than a local one. Its focus on Accountable Care Organizations (ACOs) demonstrates that national health policy makers want to pay health systems a fixed dollar amount to provide care to a population of people. This approach stands in stark contrast to the free-spending, no-one-looks-at-the-price-tag-approach the federal government fostered with the laws that launched Medicare and, to a lesser extent Medicaid, in the 1960s.

Reform became inevitable when General Motors spent more on health care in 1 year than it did on steel. Something had to give.

And physicians are responsible for part of the problem. A significant health care spending variance has been documented. Differences in what physicians order vary by region, with rates for a specific procedure being 10 times higher in some parts of the country than others.

While hip fracture rates are stable across the country, the rate of hip replacement surgeries done for arthritis varies widely. In truth, the unexplained variance is due to provider-induced demand, as has been documented by Dartmouth College researchers.

If physicians do not tackle this problem, others will.

The law’s emphasis on ACOs may have rheumatologists, as specialists who fall outside the primary care umbrella, feeling disenfranchised. As health care reform becomes more mature, private payers are going to move fast to cap spending.

Physicians must resist the urge to ignore the events going on around them; they must get involved with an eye to improving the outcome of health care reform for their specialty.

An aptitude for problem solving is why many physicians chose medical school in the first place, but how to fit into the new world order is not the problem that we signed up for when choosing medical school.

This problem is societal, economic, ethical, clinical, and personal. Physicians hate being told what to do. It annoys us. Having to get prior consent annoys us. But things are going to change whether we are part of the process or not, whether we like it or not.

To be part of the solution, physicians need to get informed. There is a lot being written. Discuss issues with local thought leaders.

The challenge of shaping medicine in the midst of health care reform belongs most to physicians who have at least 10 more years to practice. Tag, you’re it, the leaders of the change. Start acting the part.

The first steps may include joining the county medical society to get to know the other physicians in the area. Find out who the key opinion leaders are in your region and meet them. And read many perspective pieces on health care reform, Medicare, and other cost and political issues of importance, and become informed about the subjects and the arguments for and against them.

Dr. Karen S. Kolba, chair of the American College of Rheumatology Committee on Rheumatologic Care, is in private practice in Santa Maria, Calif. She reported having no relevant financial disclosures.

All health care is local, as the late Speaker of the House Tip O’Neill so famously noted about politics. And politics is at least part of the reason why we physicians face the challenges we do in health care reform.

The Affordable Care Act takes a broad approach to health care reform, rather than a local one. Its focus on Accountable Care Organizations (ACOs) demonstrates that national health policy makers want to pay health systems a fixed dollar amount to provide care to a population of people. This approach stands in stark contrast to the free-spending, no-one-looks-at-the-price-tag-approach the federal government fostered with the laws that launched Medicare and, to a lesser extent Medicaid, in the 1960s.

Reform became inevitable when General Motors spent more on health care in 1 year than it did on steel. Something had to give.

And physicians are responsible for part of the problem. A significant health care spending variance has been documented. Differences in what physicians order vary by region, with rates for a specific procedure being 10 times higher in some parts of the country than others.

While hip fracture rates are stable across the country, the rate of hip replacement surgeries done for arthritis varies widely. In truth, the unexplained variance is due to provider-induced demand, as has been documented by Dartmouth College researchers.

If physicians do not tackle this problem, others will.

The law’s emphasis on ACOs may have rheumatologists, as specialists who fall outside the primary care umbrella, feeling disenfranchised. As health care reform becomes more mature, private payers are going to move fast to cap spending.

Physicians must resist the urge to ignore the events going on around them; they must get involved with an eye to improving the outcome of health care reform for their specialty.

An aptitude for problem solving is why many physicians chose medical school in the first place, but how to fit into the new world order is not the problem that we signed up for when choosing medical school.

This problem is societal, economic, ethical, clinical, and personal. Physicians hate being told what to do. It annoys us. Having to get prior consent annoys us. But things are going to change whether we are part of the process or not, whether we like it or not.

To be part of the solution, physicians need to get informed. There is a lot being written. Discuss issues with local thought leaders.

The challenge of shaping medicine in the midst of health care reform belongs most to physicians who have at least 10 more years to practice. Tag, you’re it, the leaders of the change. Start acting the part.

The first steps may include joining the county medical society to get to know the other physicians in the area. Find out who the key opinion leaders are in your region and meet them. And read many perspective pieces on health care reform, Medicare, and other cost and political issues of importance, and become informed about the subjects and the arguments for and against them.

Dr. Karen S. Kolba, chair of the American College of Rheumatology Committee on Rheumatologic Care, is in private practice in Santa Maria, Calif. She reported having no relevant financial disclosures.

All health care is local, as the late Speaker of the House Tip O’Neill so famously noted about politics. And politics is at least part of the reason why we physicians face the challenges we do in health care reform.

The Affordable Care Act takes a broad approach to health care reform, rather than a local one. Its focus on Accountable Care Organizations (ACOs) demonstrates that national health policy makers want to pay health systems a fixed dollar amount to provide care to a population of people. This approach stands in stark contrast to the free-spending, no-one-looks-at-the-price-tag-approach the federal government fostered with the laws that launched Medicare and, to a lesser extent Medicaid, in the 1960s.

Reform became inevitable when General Motors spent more on health care in 1 year than it did on steel. Something had to give.

And physicians are responsible for part of the problem. A significant health care spending variance has been documented. Differences in what physicians order vary by region, with rates for a specific procedure being 10 times higher in some parts of the country than others.

While hip fracture rates are stable across the country, the rate of hip replacement surgeries done for arthritis varies widely. In truth, the unexplained variance is due to provider-induced demand, as has been documented by Dartmouth College researchers.

If physicians do not tackle this problem, others will.

The law’s emphasis on ACOs may have rheumatologists, as specialists who fall outside the primary care umbrella, feeling disenfranchised. As health care reform becomes more mature, private payers are going to move fast to cap spending.

Physicians must resist the urge to ignore the events going on around them; they must get involved with an eye to improving the outcome of health care reform for their specialty.

An aptitude for problem solving is why many physicians chose medical school in the first place, but how to fit into the new world order is not the problem that we signed up for when choosing medical school.

This problem is societal, economic, ethical, clinical, and personal. Physicians hate being told what to do. It annoys us. Having to get prior consent annoys us. But things are going to change whether we are part of the process or not, whether we like it or not.

To be part of the solution, physicians need to get informed. There is a lot being written. Discuss issues with local thought leaders.

The challenge of shaping medicine in the midst of health care reform belongs most to physicians who have at least 10 more years to practice. Tag, you’re it, the leaders of the change. Start acting the part.

The first steps may include joining the county medical society to get to know the other physicians in the area. Find out who the key opinion leaders are in your region and meet them. And read many perspective pieces on health care reform, Medicare, and other cost and political issues of importance, and become informed about the subjects and the arguments for and against them.

Dr. Karen S. Kolba, chair of the American College of Rheumatology Committee on Rheumatologic Care, is in private practice in Santa Maria, Calif. She reported having no relevant financial disclosures.

SAN FRANCISCO – Methotrexate is not a disease-modifying antirheumatic drug in psoriatic arthritis, despite how well it works in psoriasis, according to Dr. Christopher T. Ritchlin.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence. There have been only two published double-blind, randomized, controlled trials of methotrexate in PsA done over the last 20 years, and both were underpowered and used a low dose of methotrexate (10 mg/week), said Dr. Ritchlin, professor of medicine and director of the clinical immunology research center at the University of Rochester (N.Y.).

A still-unpublished study that was presented at the annual meeting of the American College of Rheumatology in 2010 showed that methotrexate was not more effective than placebo in PsA (Arthritis Rheum. 2010:62 [suppl.]:S277, abstract 664). The study involved 221 patients who were given 15 mg/week of methotrexate or placebo for 6 months. About 65% of subjects in each group dropped out. The primary outcome measure was the psoriatic arthritis response criteria (PsARC), which most rheumatologists do not think is a good outcome measure, Dr. Ritchlin said at the Perspectives in Rheumatic Diseases 2011 meeting.

At the end of 3 and 6 months of the study, there were no differences between methotrexate and placebo on the PsARC, the ACR 20 (the American College of Rheumatology scale based on a 20% improvement in certain parameters), the DAS28 (Disease Activity Score based on a 28-joint count), a sensitive joint count, a tender joint count, and the C-reactive protein level/erythrocyte sedimentation rates. Only the patient and physician global scores and the skin score showed significant improvement in the methotrexate group.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence.

Another unpublished study, conducted in the former Soviet Union and presented at the ARC’s annual meeting in 2009, showed the opposite. The researchers compared infliximab vs. methotrexate in methotrexate-naive patients. The dosage used was 15-20 mg/week. They found that 66% of the patients achieved an ACR 20 improvement on methotrexate alone, as did 86% of those on methotrexate plus infliximab. Remissions according to the DAS28 were reported in 30% of those on methotrexate and in 69% of those on combination therapy.

Although it may be possible to find methotrexate-naive patients in the former Soviet Union, such patients are much less likely to walk into their rheumatologist’s office in the West.

Indirect data supporting the inefficacy of methotrexate come from NOR-DMARD. These data show that 6 months of treatment with a tumor necrosis factor inhibitor (146 patients) had significantly greater beneficial effects on patients with PsA than did methotrexate (356 patients) (Ann. Rheum. Dis. 2007;66:1038-42).

The propensity toward liver disease is another reason not to use methotrexate in patients with PsA, said Dr. Ritchlin at the meeting, which was sponsored by Skin Disease Education Foundation. Methotrexate is hepatotoxic. Data on the findings of 169 liver biopsies that were done on 71 patients with psoriasis showed that methotrexate significantly increased the risk for stage 3 or 4 fibrosis. The risk was highest in obese patients or those with diabetes (J. Hepatol. 2007;46:1111-8).

These findings serve to support "my own bias that this is due to their fatty livers," which have developed as a consequence of their obesity, a common comorbidity in PsA, he said. Another cause of fatty liver in this population may be the metabolic syndrome that often develops in patients with psoriasis.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Methotrexate is not a disease-modifying antirheumatic drug in psoriatic arthritis, despite how well it works in psoriasis, according to Dr. Christopher T. Ritchlin.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence. There have been only two published double-blind, randomized, controlled trials of methotrexate in PsA done over the last 20 years, and both were underpowered and used a low dose of methotrexate (10 mg/week), said Dr. Ritchlin, professor of medicine and director of the clinical immunology research center at the University of Rochester (N.Y.).

A still-unpublished study that was presented at the annual meeting of the American College of Rheumatology in 2010 showed that methotrexate was not more effective than placebo in PsA (Arthritis Rheum. 2010:62 [suppl.]:S277, abstract 664). The study involved 221 patients who were given 15 mg/week of methotrexate or placebo for 6 months. About 65% of subjects in each group dropped out. The primary outcome measure was the psoriatic arthritis response criteria (PsARC), which most rheumatologists do not think is a good outcome measure, Dr. Ritchlin said at the Perspectives in Rheumatic Diseases 2011 meeting.

At the end of 3 and 6 months of the study, there were no differences between methotrexate and placebo on the PsARC, the ACR 20 (the American College of Rheumatology scale based on a 20% improvement in certain parameters), the DAS28 (Disease Activity Score based on a 28-joint count), a sensitive joint count, a tender joint count, and the C-reactive protein level/erythrocyte sedimentation rates. Only the patient and physician global scores and the skin score showed significant improvement in the methotrexate group.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence.

Another unpublished study, conducted in the former Soviet Union and presented at the ARC’s annual meeting in 2009, showed the opposite. The researchers compared infliximab vs. methotrexate in methotrexate-naive patients. The dosage used was 15-20 mg/week. They found that 66% of the patients achieved an ACR 20 improvement on methotrexate alone, as did 86% of those on methotrexate plus infliximab. Remissions according to the DAS28 were reported in 30% of those on methotrexate and in 69% of those on combination therapy.

Although it may be possible to find methotrexate-naive patients in the former Soviet Union, such patients are much less likely to walk into their rheumatologist’s office in the West.

Indirect data supporting the inefficacy of methotrexate come from NOR-DMARD. These data show that 6 months of treatment with a tumor necrosis factor inhibitor (146 patients) had significantly greater beneficial effects on patients with PsA than did methotrexate (356 patients) (Ann. Rheum. Dis. 2007;66:1038-42).

The propensity toward liver disease is another reason not to use methotrexate in patients with PsA, said Dr. Ritchlin at the meeting, which was sponsored by Skin Disease Education Foundation. Methotrexate is hepatotoxic. Data on the findings of 169 liver biopsies that were done on 71 patients with psoriasis showed that methotrexate significantly increased the risk for stage 3 or 4 fibrosis. The risk was highest in obese patients or those with diabetes (J. Hepatol. 2007;46:1111-8).

These findings serve to support "my own bias that this is due to their fatty livers," which have developed as a consequence of their obesity, a common comorbidity in PsA, he said. Another cause of fatty liver in this population may be the metabolic syndrome that often develops in patients with psoriasis.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Methotrexate is not a disease-modifying antirheumatic drug in psoriatic arthritis, despite how well it works in psoriasis, according to Dr. Christopher T. Ritchlin.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence. There have been only two published double-blind, randomized, controlled trials of methotrexate in PsA done over the last 20 years, and both were underpowered and used a low dose of methotrexate (10 mg/week), said Dr. Ritchlin, professor of medicine and director of the clinical immunology research center at the University of Rochester (N.Y.).

A still-unpublished study that was presented at the annual meeting of the American College of Rheumatology in 2010 showed that methotrexate was not more effective than placebo in PsA (Arthritis Rheum. 2010:62 [suppl.]:S277, abstract 664). The study involved 221 patients who were given 15 mg/week of methotrexate or placebo for 6 months. About 65% of subjects in each group dropped out. The primary outcome measure was the psoriatic arthritis response criteria (PsARC), which most rheumatologists do not think is a good outcome measure, Dr. Ritchlin said at the Perspectives in Rheumatic Diseases 2011 meeting.

At the end of 3 and 6 months of the study, there were no differences between methotrexate and placebo on the PsARC, the ACR 20 (the American College of Rheumatology scale based on a 20% improvement in certain parameters), the DAS28 (Disease Activity Score based on a 28-joint count), a sensitive joint count, a tender joint count, and the C-reactive protein level/erythrocyte sedimentation rates. Only the patient and physician global scores and the skin score showed significant improvement in the methotrexate group.

Methotrexate is the most widely used drug in the world for psoriatic arthritis (PsA), based on almost no supporting evidence.

Another unpublished study, conducted in the former Soviet Union and presented at the ARC’s annual meeting in 2009, showed the opposite. The researchers compared infliximab vs. methotrexate in methotrexate-naive patients. The dosage used was 15-20 mg/week. They found that 66% of the patients achieved an ACR 20 improvement on methotrexate alone, as did 86% of those on methotrexate plus infliximab. Remissions according to the DAS28 were reported in 30% of those on methotrexate and in 69% of those on combination therapy.

Although it may be possible to find methotrexate-naive patients in the former Soviet Union, such patients are much less likely to walk into their rheumatologist’s office in the West.

Indirect data supporting the inefficacy of methotrexate come from NOR-DMARD. These data show that 6 months of treatment with a tumor necrosis factor inhibitor (146 patients) had significantly greater beneficial effects on patients with PsA than did methotrexate (356 patients) (Ann. Rheum. Dis. 2007;66:1038-42).

The propensity toward liver disease is another reason not to use methotrexate in patients with PsA, said Dr. Ritchlin at the meeting, which was sponsored by Skin Disease Education Foundation. Methotrexate is hepatotoxic. Data on the findings of 169 liver biopsies that were done on 71 patients with psoriasis showed that methotrexate significantly increased the risk for stage 3 or 4 fibrosis. The risk was highest in obese patients or those with diabetes (J. Hepatol. 2007;46:1111-8).

These findings serve to support "my own bias that this is due to their fatty livers," which have developed as a consequence of their obesity, a common comorbidity in PsA, he said. Another cause of fatty liver in this population may be the metabolic syndrome that often develops in patients with psoriasis.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Most patients with systemic lupus nephritis should be on hydroxychloroquine, according to guidelines on the management of lupus nephritis to be issued by the American College of Rheumatology.

Renal involvement increases mortality in patients with systemic lupus erythematosus (SLE). About 95% of patients with lupus survive 10 years. That was not true 25 years ago; mortality was much worse. "Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn, division chief and professor of rheumatology at the University of California, Los Angeles.

However, when the lupus patient has nephritis, survival drops to 85% for all races combined. For blacks and Hispanics, the 10-year year survival is even worse.

Guidelines on the management of lupus nephritis have been developed by a committee of the American College of Rheumatology, which Dr. Hahn chairs. Those guidelines will be published after review by several ACR committees.

Hydroxychloroquine is one of the reasons that outcomes have improved so much for patients with SLE. Data from a study of 518 patients who had SLE for less than 5 years showed that 56% of them were on hydroxychloroquine at the time of enrollment, said Dr. Hahn at the Perspectives in Rheumatic Diseases 2011 meeting.

"Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn.

Use of hydroxychloroquine was associated with a reduced risk for developing new damage (hazard ratio, 0.73; 95% confidence interval, 0.52-1.00; P = .05). Of note, patients on hydroxychloroquine who had no damage at study entry had a statistically significant decrease in the risk of developing any organ damage (HR, 0.55; 95% CI, 0.34-0.87; P = .0111), whereas those on hydroxychloroquine who had damage at study entry did not (HR, 1.106; 95% CI, 0.70-1.74; P = .6630) (Arthritis Rheum. 2005;52:1473-80).

The big stick in the management of lupus is glucocorticoids. Rheumatologists have known since 1985 that high-dose intravenous glucocorticoids save lives. Intravenous cyclophosphamide preserved renal function better than steroids or steroids plus azathioprine in patients with class IV lupus nephritis. It became the standard of care for close to 10 years, based on research done at the National Institutes of Health (Arthritis Rheum. 2002;46:2121-31).

Because of its side effects, "patients absolutely despise cyclophosphamide" and it takes a long time to work, noted Dr. Hahn at the meeting, which was sponsored by Skin Disease Education Foundation.

However, mycophenolate seems to produce outcomes that are comparable to those from cyclophosphamide. Findings from a study of 364 patients with acute lupus nephritis showed that, overall, 6 months of induction treatment with mycophenolate worked as well as cyclophosphamide in whites. However, blacks and Hispanics have a significantly lower response to cyclophosphamide than to mycophenolate (J. Am. Soc. Nephrol. 2009;20:1103-12).

Dr. Hahn urged the audience to keep in mind that mycophenolate is a teratogen, but added that in all other respects the two agents are equally safe (J. Rheumatol. 2011;38:69-78).

Dr. Hahn reported financial relationships with Abbott, Aspreva, Teva, and UCB. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Most patients with systemic lupus nephritis should be on hydroxychloroquine, according to guidelines on the management of lupus nephritis to be issued by the American College of Rheumatology.

Renal involvement increases mortality in patients with systemic lupus erythematosus (SLE). About 95% of patients with lupus survive 10 years. That was not true 25 years ago; mortality was much worse. "Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn, division chief and professor of rheumatology at the University of California, Los Angeles.

However, when the lupus patient has nephritis, survival drops to 85% for all races combined. For blacks and Hispanics, the 10-year year survival is even worse.

Guidelines on the management of lupus nephritis have been developed by a committee of the American College of Rheumatology, which Dr. Hahn chairs. Those guidelines will be published after review by several ACR committees.

Hydroxychloroquine is one of the reasons that outcomes have improved so much for patients with SLE. Data from a study of 518 patients who had SLE for less than 5 years showed that 56% of them were on hydroxychloroquine at the time of enrollment, said Dr. Hahn at the Perspectives in Rheumatic Diseases 2011 meeting.

"Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn.

Use of hydroxychloroquine was associated with a reduced risk for developing new damage (hazard ratio, 0.73; 95% confidence interval, 0.52-1.00; P = .05). Of note, patients on hydroxychloroquine who had no damage at study entry had a statistically significant decrease in the risk of developing any organ damage (HR, 0.55; 95% CI, 0.34-0.87; P = .0111), whereas those on hydroxychloroquine who had damage at study entry did not (HR, 1.106; 95% CI, 0.70-1.74; P = .6630) (Arthritis Rheum. 2005;52:1473-80).

The big stick in the management of lupus is glucocorticoids. Rheumatologists have known since 1985 that high-dose intravenous glucocorticoids save lives. Intravenous cyclophosphamide preserved renal function better than steroids or steroids plus azathioprine in patients with class IV lupus nephritis. It became the standard of care for close to 10 years, based on research done at the National Institutes of Health (Arthritis Rheum. 2002;46:2121-31).

Because of its side effects, "patients absolutely despise cyclophosphamide" and it takes a long time to work, noted Dr. Hahn at the meeting, which was sponsored by Skin Disease Education Foundation.

However, mycophenolate seems to produce outcomes that are comparable to those from cyclophosphamide. Findings from a study of 364 patients with acute lupus nephritis showed that, overall, 6 months of induction treatment with mycophenolate worked as well as cyclophosphamide in whites. However, blacks and Hispanics have a significantly lower response to cyclophosphamide than to mycophenolate (J. Am. Soc. Nephrol. 2009;20:1103-12).

Dr. Hahn urged the audience to keep in mind that mycophenolate is a teratogen, but added that in all other respects the two agents are equally safe (J. Rheumatol. 2011;38:69-78).

Dr. Hahn reported financial relationships with Abbott, Aspreva, Teva, and UCB. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Most patients with systemic lupus nephritis should be on hydroxychloroquine, according to guidelines on the management of lupus nephritis to be issued by the American College of Rheumatology.

Renal involvement increases mortality in patients with systemic lupus erythematosus (SLE). About 95% of patients with lupus survive 10 years. That was not true 25 years ago; mortality was much worse. "Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn, division chief and professor of rheumatology at the University of California, Los Angeles.

However, when the lupus patient has nephritis, survival drops to 85% for all races combined. For blacks and Hispanics, the 10-year year survival is even worse.

Guidelines on the management of lupus nephritis have been developed by a committee of the American College of Rheumatology, which Dr. Hahn chairs. Those guidelines will be published after review by several ACR committees.

Hydroxychloroquine is one of the reasons that outcomes have improved so much for patients with SLE. Data from a study of 518 patients who had SLE for less than 5 years showed that 56% of them were on hydroxychloroquine at the time of enrollment, said Dr. Hahn at the Perspectives in Rheumatic Diseases 2011 meeting.

"Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn.

Use of hydroxychloroquine was associated with a reduced risk for developing new damage (hazard ratio, 0.73; 95% confidence interval, 0.52-1.00; P = .05). Of note, patients on hydroxychloroquine who had no damage at study entry had a statistically significant decrease in the risk of developing any organ damage (HR, 0.55; 95% CI, 0.34-0.87; P = .0111), whereas those on hydroxychloroquine who had damage at study entry did not (HR, 1.106; 95% CI, 0.70-1.74; P = .6630) (Arthritis Rheum. 2005;52:1473-80).

The big stick in the management of lupus is glucocorticoids. Rheumatologists have known since 1985 that high-dose intravenous glucocorticoids save lives. Intravenous cyclophosphamide preserved renal function better than steroids or steroids plus azathioprine in patients with class IV lupus nephritis. It became the standard of care for close to 10 years, based on research done at the National Institutes of Health (Arthritis Rheum. 2002;46:2121-31).

Because of its side effects, "patients absolutely despise cyclophosphamide" and it takes a long time to work, noted Dr. Hahn at the meeting, which was sponsored by Skin Disease Education Foundation.

However, mycophenolate seems to produce outcomes that are comparable to those from cyclophosphamide. Findings from a study of 364 patients with acute lupus nephritis showed that, overall, 6 months of induction treatment with mycophenolate worked as well as cyclophosphamide in whites. However, blacks and Hispanics have a significantly lower response to cyclophosphamide than to mycophenolate (J. Am. Soc. Nephrol. 2009;20:1103-12).

Dr. Hahn urged the audience to keep in mind that mycophenolate is a teratogen, but added that in all other respects the two agents are equally safe (J. Rheumatol. 2011;38:69-78).

Dr. Hahn reported financial relationships with Abbott, Aspreva, Teva, and UCB. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – The atypical presentation of cardiovascular disease in patients with rheumatoid arthritis often masks its presence until the patient dies suddenly, according to Dr. Vibeke Strand.

The mortality in patients with RA is twice that of the normal population, with the average life span being reduced by 15-18 years in RA, which is comparable to the early mortality seen in patients with diabetes. Cardiovascular disease (CVD) explains almost all of the excess mortality seen in patients with RA, said Dr. Strand of the division of immunology and rheumatology at Stanford (Calif.) University.

CVD risk factors are atypical in RA patients. They are less likely to be obese or to have hypertension, hyperlipidemia, or diabetes (J. Rheumatol. 2011;38:29-35). Heart failure is more common in the RA population, especially in rheumatoid factor (RF)-positive patients. However despite their heart failure, their ejection fraction often remains normal.

Patients’ body mass index tends to be low, suggesting that their heart failure may result from reduced myocardial mass rather than from hypertrophy. Those with a BMI less than 20 kg/m² have a significantly decreased survival, she said at the Perspectives in Rheumatic Diseases 2011 meeting.

Because their CVD presentation is atypical, RA patients tend to get recognized later in the course of their heart disease and to be treated less aggressively. RA patients are less likely than those without the disease to undergo revascularization or receive cardiovascular medications after an MI.

Until recently, rheumatologists have been unable to lessen early mortality among RA patients. However, data from a study of 3,862 RA patients diagnosed with RA either before 1970, between 1970 and 1980, or after 1990 showed a drop in excess mortality among the 1,240 patients diagnosed after 1995. The researchers attributed the prolonged survival to the use of methotrexate (Lancet 2002;359:1173-7; Circulation 2004;110:1774-9).

With the advent of the biologics era, particularly the widespread use of tumor necrosis factor (TNF) inhibitors, rheumatologists have been wondering whether the anti-inflammatory properties of these agents would lower CVD mortality among RA patients.

Data presented at the 2005 Congress of the European League Against Rheumatism (EULAR) (abstract OP0095) showed that use of TNF inhibitors lowers the hazard ratio of all-cause mortality to 0.72 among RA patients. These findings were based on 63,811 patient-years of follow-up of 19,580 RA patients, among whom there were 1,129 deaths. Use of methotrexate was associated with an HR of 0.82. Prednisone increased the risk to an HR of 1.60, which is consistent with the well-documented risk of CVD associated with the use of even small doses of this agent, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Standard risk scores such as the Framingham score underestimate the risk for heart disease in an RA population. The underestimation is clear in the results of a study that compared mortality risk as calculated by the Framingham score with actual events in 341 women with RA aged 30-74 years and 150 men with RA aged 30-74 years. According to the Framingham score, the 10-year CVD risk for the women was 4.6%. In fact, it was 11.1%. For the men, the Framingham risk was 12%. The actual cardiovascular risk was 25.8% (Arthritis Rheum. 2009;60:S264).

The excess CVD risk persists even after traditional risk factors seen in normal populations are controlled for. The biggest remaining risk is the burden of inflammation. There are increased levels of TNF-alpha and interleukin-6 in the serum, myocardium, and synovitis of RA, according to Dr. Strand.

Recommendations on limiting the increased risk for CVD issued by EULAR (Ann. Rheum. Dis. 2010;69:325-31) suggest modifying the risk score by multiplying it by 1.5 when the patient has two of the three following signs of severe disease: RA duration of more than 10 years; rheumatoid factor and anti-CCP antibody positivity; and/or extra-articular disease manifestations.

The following steps should be taken in such patients:

• Monitor total cholesterol/high-density lipoprotein levels.

• Manage appropriate treatment with statins, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.

• Prescribe steroids at the lowest possible dose, if at all.

• Urge caution regarding the use of nonsteroidal anti-inflammatory drugs and COX-2 inhibitors.

• Urge patients to stop smoking.

Dr. Strand disclosed that she has financial relationships with many companies that make treatments for RA.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – The atypical presentation of cardiovascular disease in patients with rheumatoid arthritis often masks its presence until the patient dies suddenly, according to Dr. Vibeke Strand.

The mortality in patients with RA is twice that of the normal population, with the average life span being reduced by 15-18 years in RA, which is comparable to the early mortality seen in patients with diabetes. Cardiovascular disease (CVD) explains almost all of the excess mortality seen in patients with RA, said Dr. Strand of the division of immunology and rheumatology at Stanford (Calif.) University.

CVD risk factors are atypical in RA patients. They are less likely to be obese or to have hypertension, hyperlipidemia, or diabetes (J. Rheumatol. 2011;38:29-35). Heart failure is more common in the RA population, especially in rheumatoid factor (RF)-positive patients. However despite their heart failure, their ejection fraction often remains normal.

Patients’ body mass index tends to be low, suggesting that their heart failure may result from reduced myocardial mass rather than from hypertrophy. Those with a BMI less than 20 kg/m² have a significantly decreased survival, she said at the Perspectives in Rheumatic Diseases 2011 meeting.

Because their CVD presentation is atypical, RA patients tend to get recognized later in the course of their heart disease and to be treated less aggressively. RA patients are less likely than those without the disease to undergo revascularization or receive cardiovascular medications after an MI.

Until recently, rheumatologists have been unable to lessen early mortality among RA patients. However, data from a study of 3,862 RA patients diagnosed with RA either before 1970, between 1970 and 1980, or after 1990 showed a drop in excess mortality among the 1,240 patients diagnosed after 1995. The researchers attributed the prolonged survival to the use of methotrexate (Lancet 2002;359:1173-7; Circulation 2004;110:1774-9).

With the advent of the biologics era, particularly the widespread use of tumor necrosis factor (TNF) inhibitors, rheumatologists have been wondering whether the anti-inflammatory properties of these agents would lower CVD mortality among RA patients.

Data presented at the 2005 Congress of the European League Against Rheumatism (EULAR) (abstract OP0095) showed that use of TNF inhibitors lowers the hazard ratio of all-cause mortality to 0.72 among RA patients. These findings were based on 63,811 patient-years of follow-up of 19,580 RA patients, among whom there were 1,129 deaths. Use of methotrexate was associated with an HR of 0.82. Prednisone increased the risk to an HR of 1.60, which is consistent with the well-documented risk of CVD associated with the use of even small doses of this agent, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Standard risk scores such as the Framingham score underestimate the risk for heart disease in an RA population. The underestimation is clear in the results of a study that compared mortality risk as calculated by the Framingham score with actual events in 341 women with RA aged 30-74 years and 150 men with RA aged 30-74 years. According to the Framingham score, the 10-year CVD risk for the women was 4.6%. In fact, it was 11.1%. For the men, the Framingham risk was 12%. The actual cardiovascular risk was 25.8% (Arthritis Rheum. 2009;60:S264).

The excess CVD risk persists even after traditional risk factors seen in normal populations are controlled for. The biggest remaining risk is the burden of inflammation. There are increased levels of TNF-alpha and interleukin-6 in the serum, myocardium, and synovitis of RA, according to Dr. Strand.

Recommendations on limiting the increased risk for CVD issued by EULAR (Ann. Rheum. Dis. 2010;69:325-31) suggest modifying the risk score by multiplying it by 1.5 when the patient has two of the three following signs of severe disease: RA duration of more than 10 years; rheumatoid factor and anti-CCP antibody positivity; and/or extra-articular disease manifestations.

The following steps should be taken in such patients:

• Monitor total cholesterol/high-density lipoprotein levels.

• Manage appropriate treatment with statins, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.

• Prescribe steroids at the lowest possible dose, if at all.

• Urge caution regarding the use of nonsteroidal anti-inflammatory drugs and COX-2 inhibitors.

• Urge patients to stop smoking.

Dr. Strand disclosed that she has financial relationships with many companies that make treatments for RA.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – The atypical presentation of cardiovascular disease in patients with rheumatoid arthritis often masks its presence until the patient dies suddenly, according to Dr. Vibeke Strand.

The mortality in patients with RA is twice that of the normal population, with the average life span being reduced by 15-18 years in RA, which is comparable to the early mortality seen in patients with diabetes. Cardiovascular disease (CVD) explains almost all of the excess mortality seen in patients with RA, said Dr. Strand of the division of immunology and rheumatology at Stanford (Calif.) University.

CVD risk factors are atypical in RA patients. They are less likely to be obese or to have hypertension, hyperlipidemia, or diabetes (J. Rheumatol. 2011;38:29-35). Heart failure is more common in the RA population, especially in rheumatoid factor (RF)-positive patients. However despite their heart failure, their ejection fraction often remains normal.

Patients’ body mass index tends to be low, suggesting that their heart failure may result from reduced myocardial mass rather than from hypertrophy. Those with a BMI less than 20 kg/m² have a significantly decreased survival, she said at the Perspectives in Rheumatic Diseases 2011 meeting.

Because their CVD presentation is atypical, RA patients tend to get recognized later in the course of their heart disease and to be treated less aggressively. RA patients are less likely than those without the disease to undergo revascularization or receive cardiovascular medications after an MI.

Until recently, rheumatologists have been unable to lessen early mortality among RA patients. However, data from a study of 3,862 RA patients diagnosed with RA either before 1970, between 1970 and 1980, or after 1990 showed a drop in excess mortality among the 1,240 patients diagnosed after 1995. The researchers attributed the prolonged survival to the use of methotrexate (Lancet 2002;359:1173-7; Circulation 2004;110:1774-9).

With the advent of the biologics era, particularly the widespread use of tumor necrosis factor (TNF) inhibitors, rheumatologists have been wondering whether the anti-inflammatory properties of these agents would lower CVD mortality among RA patients.

Data presented at the 2005 Congress of the European League Against Rheumatism (EULAR) (abstract OP0095) showed that use of TNF inhibitors lowers the hazard ratio of all-cause mortality to 0.72 among RA patients. These findings were based on 63,811 patient-years of follow-up of 19,580 RA patients, among whom there were 1,129 deaths. Use of methotrexate was associated with an HR of 0.82. Prednisone increased the risk to an HR of 1.60, which is consistent with the well-documented risk of CVD associated with the use of even small doses of this agent, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Standard risk scores such as the Framingham score underestimate the risk for heart disease in an RA population. The underestimation is clear in the results of a study that compared mortality risk as calculated by the Framingham score with actual events in 341 women with RA aged 30-74 years and 150 men with RA aged 30-74 years. According to the Framingham score, the 10-year CVD risk for the women was 4.6%. In fact, it was 11.1%. For the men, the Framingham risk was 12%. The actual cardiovascular risk was 25.8% (Arthritis Rheum. 2009;60:S264).

The excess CVD risk persists even after traditional risk factors seen in normal populations are controlled for. The biggest remaining risk is the burden of inflammation. There are increased levels of TNF-alpha and interleukin-6 in the serum, myocardium, and synovitis of RA, according to Dr. Strand.

Recommendations on limiting the increased risk for CVD issued by EULAR (Ann. Rheum. Dis. 2010;69:325-31) suggest modifying the risk score by multiplying it by 1.5 when the patient has two of the three following signs of severe disease: RA duration of more than 10 years; rheumatoid factor and anti-CCP antibody positivity; and/or extra-articular disease manifestations.

The following steps should be taken in such patients:

• Monitor total cholesterol/high-density lipoprotein levels.

• Manage appropriate treatment with statins, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.

• Prescribe steroids at the lowest possible dose, if at all.

• Urge caution regarding the use of nonsteroidal anti-inflammatory drugs and COX-2 inhibitors.

• Urge patients to stop smoking.

Dr. Strand disclosed that she has financial relationships with many companies that make treatments for RA.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Rheumatologists can prescribe drugs that can not only drive rheumatoid arthritis into remission but can also achieve some repair to the joints damaged by inflammation, according to Dr. Marc D. Cohen.

"In rheumatology, remission can never mean no disease. It just means not very much disease," said Dr. Cohen, emeritus professor of medicine at the Mayo Clinic, Rochester, Minn., and acting chief and professor of medicine at National Jewish Medical and Research Center in Denver.

"Rheumatologists need to be better sellers of what we can do. If you are not interested in changing the face of this disease, what are you doing?" he asked at the Perspectives in Rheumatic Diseases 2011 meeting.

In a review of the data on the efficacy of various biologic drugs in rheumatoid arthritis (RA), Dr. Cohen pointed out that, until the advent of biologics, there were no good trial data on the efficacy of methotrexate in RA. "The biologics are the best thing that ever happened to methotrexate, believe me," he said.

The study that put methotrexate on the map was the SWEFOT, in which investigators put all patients with RA on a trial of methotrexate before randomizing them to either triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine or to methotrexate plus a tumor necrosis factor inhibitor (TNFi). The findings from the methotrexate-monotherapy portion of the trial showed that 30% of the patients improved on methotrexate alone (Lancet 2009;374:459-66).

Because of these findings, all patients get a trial of methotrexate first, as quickly as possible, ramping up the dose over 1-2 months, to see what happens. What may get overlooked is the investigators’ note that, while a subset of patients experience clinical benefit from methotrexate monotherapy, radiographic disease progression continues despite methotrexate making the patients feel better.

There is no way to predict which 30% may respond clinically to methotrexate. That is one reason why one may want to rush through ramping up the dose.

Commonly, the next step in treating RA is to apply triple therapy. Further findings from the SWEFOT trial of 487 patients with RA symptoms of less than 1 year’s duration showed that clinically at 2 years the two treatment groups were the same in terms of Disease Activity Score (DAS). However, patients given triple therapy had more radiographic progression than did those given a TNFi plus methotrexate.

"Is that important to your patient? I am not sure. The problem is that we have no way to measure that. We need a point system. If you have RA in your right big toe and you are a piano player that is probably not as bad as having wrist disease. Maybe we should weight them."

The bottom line is that the addition of a TNFi to the treatment regimen of someone who did not respond completely to methotrexate will improve the clinical and radiologic response in two to three times the number of patients (Lancet 2007;370:1861-74).

This combination approach does not capture everyone.

This is part of the motivation behind the push for primary care physicians to recognize RA early and get the patients to the rheumatologists for biologic therapy early. When the biologics are given aggressively within the first 6 months of the disease, "we may be able to reset the disease, turn it off," he said.

In some cases, x-rays show repair of the joint damage when biologics are given early enough, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Dr. Paul Emery, professor of rheumatology and head of the academic unit of musculoskeletal medicine at the University of Leeds (England), presented data at the 2011 EULAR Congress showing that after patients achieved remission with methotrexate and a biologic, they could be maintained on methotrexate. This approach has the advantage of maintaining remission with a less-costly drug that also poses fewer potentially adverse effects than a biologic agent. "We do not know the right combination initially, but it is being examined," said Dr. Cohen.

SDEF and this news organization are owned by Elsevier.

Dr. Cohen reported having no relevant conflicts of interest to disclose.

SAN FRANCISCO – Rheumatologists can prescribe drugs that can not only drive rheumatoid arthritis into remission but can also achieve some repair to the joints damaged by inflammation, according to Dr. Marc D. Cohen.

"In rheumatology, remission can never mean no disease. It just means not very much disease," said Dr. Cohen, emeritus professor of medicine at the Mayo Clinic, Rochester, Minn., and acting chief and professor of medicine at National Jewish Medical and Research Center in Denver.

"Rheumatologists need to be better sellers of what we can do. If you are not interested in changing the face of this disease, what are you doing?" he asked at the Perspectives in Rheumatic Diseases 2011 meeting.

In a review of the data on the efficacy of various biologic drugs in rheumatoid arthritis (RA), Dr. Cohen pointed out that, until the advent of biologics, there were no good trial data on the efficacy of methotrexate in RA. "The biologics are the best thing that ever happened to methotrexate, believe me," he said.

The study that put methotrexate on the map was the SWEFOT, in which investigators put all patients with RA on a trial of methotrexate before randomizing them to either triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine or to methotrexate plus a tumor necrosis factor inhibitor (TNFi). The findings from the methotrexate-monotherapy portion of the trial showed that 30% of the patients improved on methotrexate alone (Lancet 2009;374:459-66).

Because of these findings, all patients get a trial of methotrexate first, as quickly as possible, ramping up the dose over 1-2 months, to see what happens. What may get overlooked is the investigators’ note that, while a subset of patients experience clinical benefit from methotrexate monotherapy, radiographic disease progression continues despite methotrexate making the patients feel better.

There is no way to predict which 30% may respond clinically to methotrexate. That is one reason why one may want to rush through ramping up the dose.

Commonly, the next step in treating RA is to apply triple therapy. Further findings from the SWEFOT trial of 487 patients with RA symptoms of less than 1 year’s duration showed that clinically at 2 years the two treatment groups were the same in terms of Disease Activity Score (DAS). However, patients given triple therapy had more radiographic progression than did those given a TNFi plus methotrexate.

"Is that important to your patient? I am not sure. The problem is that we have no way to measure that. We need a point system. If you have RA in your right big toe and you are a piano player that is probably not as bad as having wrist disease. Maybe we should weight them."

The bottom line is that the addition of a TNFi to the treatment regimen of someone who did not respond completely to methotrexate will improve the clinical and radiologic response in two to three times the number of patients (Lancet 2007;370:1861-74).

This combination approach does not capture everyone.

This is part of the motivation behind the push for primary care physicians to recognize RA early and get the patients to the rheumatologists for biologic therapy early. When the biologics are given aggressively within the first 6 months of the disease, "we may be able to reset the disease, turn it off," he said.

In some cases, x-rays show repair of the joint damage when biologics are given early enough, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Dr. Paul Emery, professor of rheumatology and head of the academic unit of musculoskeletal medicine at the University of Leeds (England), presented data at the 2011 EULAR Congress showing that after patients achieved remission with methotrexate and a biologic, they could be maintained on methotrexate. This approach has the advantage of maintaining remission with a less-costly drug that also poses fewer potentially adverse effects than a biologic agent. "We do not know the right combination initially, but it is being examined," said Dr. Cohen.

SDEF and this news organization are owned by Elsevier.

Dr. Cohen reported having no relevant conflicts of interest to disclose.

SAN FRANCISCO – Rheumatologists can prescribe drugs that can not only drive rheumatoid arthritis into remission but can also achieve some repair to the joints damaged by inflammation, according to Dr. Marc D. Cohen.

"In rheumatology, remission can never mean no disease. It just means not very much disease," said Dr. Cohen, emeritus professor of medicine at the Mayo Clinic, Rochester, Minn., and acting chief and professor of medicine at National Jewish Medical and Research Center in Denver.

"Rheumatologists need to be better sellers of what we can do. If you are not interested in changing the face of this disease, what are you doing?" he asked at the Perspectives in Rheumatic Diseases 2011 meeting.

In a review of the data on the efficacy of various biologic drugs in rheumatoid arthritis (RA), Dr. Cohen pointed out that, until the advent of biologics, there were no good trial data on the efficacy of methotrexate in RA. "The biologics are the best thing that ever happened to methotrexate, believe me," he said.

The study that put methotrexate on the map was the SWEFOT, in which investigators put all patients with RA on a trial of methotrexate before randomizing them to either triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine or to methotrexate plus a tumor necrosis factor inhibitor (TNFi). The findings from the methotrexate-monotherapy portion of the trial showed that 30% of the patients improved on methotrexate alone (Lancet 2009;374:459-66).

Because of these findings, all patients get a trial of methotrexate first, as quickly as possible, ramping up the dose over 1-2 months, to see what happens. What may get overlooked is the investigators’ note that, while a subset of patients experience clinical benefit from methotrexate monotherapy, radiographic disease progression continues despite methotrexate making the patients feel better.

There is no way to predict which 30% may respond clinically to methotrexate. That is one reason why one may want to rush through ramping up the dose.

Commonly, the next step in treating RA is to apply triple therapy. Further findings from the SWEFOT trial of 487 patients with RA symptoms of less than 1 year’s duration showed that clinically at 2 years the two treatment groups were the same in terms of Disease Activity Score (DAS). However, patients given triple therapy had more radiographic progression than did those given a TNFi plus methotrexate.

"Is that important to your patient? I am not sure. The problem is that we have no way to measure that. We need a point system. If you have RA in your right big toe and you are a piano player that is probably not as bad as having wrist disease. Maybe we should weight them."

The bottom line is that the addition of a TNFi to the treatment regimen of someone who did not respond completely to methotrexate will improve the clinical and radiologic response in two to three times the number of patients (Lancet 2007;370:1861-74).

This combination approach does not capture everyone.

This is part of the motivation behind the push for primary care physicians to recognize RA early and get the patients to the rheumatologists for biologic therapy early. When the biologics are given aggressively within the first 6 months of the disease, "we may be able to reset the disease, turn it off," he said.

In some cases, x-rays show repair of the joint damage when biologics are given early enough, he said at the meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

Dr. Paul Emery, professor of rheumatology and head of the academic unit of musculoskeletal medicine at the University of Leeds (England), presented data at the 2011 EULAR Congress showing that after patients achieved remission with methotrexate and a biologic, they could be maintained on methotrexate. This approach has the advantage of maintaining remission with a less-costly drug that also poses fewer potentially adverse effects than a biologic agent. "We do not know the right combination initially, but it is being examined," said Dr. Cohen.

SDEF and this news organization are owned by Elsevier.

Dr. Cohen reported having no relevant conflicts of interest to disclose.

SAN FRANCISCO – Patients believe that setting specific goals at the beginning of a new therapy will help them achieve optimal treatment outcomes, in a slight variation of the treat-to-target mantra heard so widely in rheumatology these days.

Findings from an unpublished survey of 1,242 women and 587 men with moderate rheumatoid arthritis (RA) disease severity showed that at the start of treatment, 81% set personal or social goals (ability to garden or stand at a cocktail party), with 80% saying that the setting of such goals would be a good way to assess whether the new treatment was working; 91% set treatment goals (an MRI will show less inflammation in the joint), according to Dr. Vibeke Strand.

Most patients (87%) agreed that establishing such targets and achieving them would have a positive impact on their disease management.

Patients’ perceptions of goal setting included:

• I think setting personal and social goals would be of benefit as I can then assess whether my treatment is working or not in a simple to understand way (80% agreed).

• A treatment that works gets me to my personal and social goals quickly (84% agreed).

• If I set myself personal and social goals and achieve them, I would feel positive (87% agreed).

But they expected rapid results. About 81% wanted a new treatment to make them feel better within 3 months, and 56% said they would talk with their physician within less than a month of starting a new treatment if they felt no improvement, said Dr. Strand, adjunct clinical professor in the division of immunology at Stanford (Calif.) University.

A few were willing to give a new treatment longer to produce a benefit, with 20% saying they expected improved signs and symptoms within 3-6 months; only 5% were willing to wait more than 6 months.

Patients are just as impatient with their physicians as with their treatments. A total of 11% cited their physician as the biggest obstacle in controlling RA. Another 54% said that the leading challenge was finding the right treatment, and 16% named lack of education and understanding of RA. The remainder was made up of 11% who said lack of personal resolve was their biggest obstacle, and another 8% listed assorted other issues.

Over half of those surveyed (60%) had not heard of the treat-to-target approach to RA therapy. According to 61%, their physician did not manage their RA with strict goals and timeframes in place. But 62% said that they shared decisions with their physician on how best to treat their RA, Dr. Strand said at the Pespectives in Rheumatic Diseases 2011 meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

This survey was a follow-up to an earlier one of 1,958 women with RA from seven countries, including the United States, which was the first to characterize in detail the impact RA has on the daily lives of women and on their relationships. The survey was conducted on the Internet; all the women had been vetted as having RA of at least 6 months duration and all were 25-65 years of age.

The bottom line from that survey is that well into the era of biologics, women with rheumatoid arthritis report that pain remains a frequent and disabling symptom of their disease. Daily pain was reported by 63% of the women surveyed; 75% said they took pain medication daily, and 87% said they found it important to be able to describe the type and frequency of their RA-associated pain. Overall, 67% of the women reported that they constantly look for new ways to cope with their pain. When asked to describe a "good day with RA," 57% said it was a day free from pain, 58% said it was a day without fatigue, and 29% said it was a day when they were able to do everything easily.

Of the surveyed women, 68% reported that they felt it was necessary to conceal pain from their family and/or coworkers.

Regarding the effects of RA on their activities of daily living, 49% said it was difficult to keep fit, 45% found it difficult to garden, and 67% reported feeling less self-confident at work. Of the women who had been employed full time at diagnosis, 23% of the women had stopped working because of their disease and 27% reported they had cut back their work hours to part time.

The impact of RA extended beyond the workplace: 32% of the women said RA affected their closest relationships, with 55% reporting that they felt less confident in their sexuality; 31% reporting that they found it difficult to explain their sexual needs; of the 611 women who were single, 40% said RA played a role in it being difficult to find a partner.

The overarching weakness of both Internet surveys is the possibility that women with the worst disease were the ones who elected to complete the questionnaire, which may have introduced some bias, Dr. Strand noted.

The survey was funded by UCB, which manufactures Cimzia (certolizumab pegol). Dr. Strand disclosed that she has financial relationships with many companies that make treatments for rheumatoid arthritis, among other things.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Patients believe that setting specific goals at the beginning of a new therapy will help them achieve optimal treatment outcomes, in a slight variation of the treat-to-target mantra heard so widely in rheumatology these days.

Findings from an unpublished survey of 1,242 women and 587 men with moderate rheumatoid arthritis (RA) disease severity showed that at the start of treatment, 81% set personal or social goals (ability to garden or stand at a cocktail party), with 80% saying that the setting of such goals would be a good way to assess whether the new treatment was working; 91% set treatment goals (an MRI will show less inflammation in the joint), according to Dr. Vibeke Strand.

Most patients (87%) agreed that establishing such targets and achieving them would have a positive impact on their disease management.

Patients’ perceptions of goal setting included:

• I think setting personal and social goals would be of benefit as I can then assess whether my treatment is working or not in a simple to understand way (80% agreed).

• A treatment that works gets me to my personal and social goals quickly (84% agreed).

• If I set myself personal and social goals and achieve them, I would feel positive (87% agreed).

But they expected rapid results. About 81% wanted a new treatment to make them feel better within 3 months, and 56% said they would talk with their physician within less than a month of starting a new treatment if they felt no improvement, said Dr. Strand, adjunct clinical professor in the division of immunology at Stanford (Calif.) University.

A few were willing to give a new treatment longer to produce a benefit, with 20% saying they expected improved signs and symptoms within 3-6 months; only 5% were willing to wait more than 6 months.

Patients are just as impatient with their physicians as with their treatments. A total of 11% cited their physician as the biggest obstacle in controlling RA. Another 54% said that the leading challenge was finding the right treatment, and 16% named lack of education and understanding of RA. The remainder was made up of 11% who said lack of personal resolve was their biggest obstacle, and another 8% listed assorted other issues.

Over half of those surveyed (60%) had not heard of the treat-to-target approach to RA therapy. According to 61%, their physician did not manage their RA with strict goals and timeframes in place. But 62% said that they shared decisions with their physician on how best to treat their RA, Dr. Strand said at the Pespectives in Rheumatic Diseases 2011 meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

This survey was a follow-up to an earlier one of 1,958 women with RA from seven countries, including the United States, which was the first to characterize in detail the impact RA has on the daily lives of women and on their relationships. The survey was conducted on the Internet; all the women had been vetted as having RA of at least 6 months duration and all were 25-65 years of age.

The bottom line from that survey is that well into the era of biologics, women with rheumatoid arthritis report that pain remains a frequent and disabling symptom of their disease. Daily pain was reported by 63% of the women surveyed; 75% said they took pain medication daily, and 87% said they found it important to be able to describe the type and frequency of their RA-associated pain. Overall, 67% of the women reported that they constantly look for new ways to cope with their pain. When asked to describe a "good day with RA," 57% said it was a day free from pain, 58% said it was a day without fatigue, and 29% said it was a day when they were able to do everything easily.

Of the surveyed women, 68% reported that they felt it was necessary to conceal pain from their family and/or coworkers.

Regarding the effects of RA on their activities of daily living, 49% said it was difficult to keep fit, 45% found it difficult to garden, and 67% reported feeling less self-confident at work. Of the women who had been employed full time at diagnosis, 23% of the women had stopped working because of their disease and 27% reported they had cut back their work hours to part time.

The impact of RA extended beyond the workplace: 32% of the women said RA affected their closest relationships, with 55% reporting that they felt less confident in their sexuality; 31% reporting that they found it difficult to explain their sexual needs; of the 611 women who were single, 40% said RA played a role in it being difficult to find a partner.

The overarching weakness of both Internet surveys is the possibility that women with the worst disease were the ones who elected to complete the questionnaire, which may have introduced some bias, Dr. Strand noted.

The survey was funded by UCB, which manufactures Cimzia (certolizumab pegol). Dr. Strand disclosed that she has financial relationships with many companies that make treatments for rheumatoid arthritis, among other things.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – Patients believe that setting specific goals at the beginning of a new therapy will help them achieve optimal treatment outcomes, in a slight variation of the treat-to-target mantra heard so widely in rheumatology these days.

Findings from an unpublished survey of 1,242 women and 587 men with moderate rheumatoid arthritis (RA) disease severity showed that at the start of treatment, 81% set personal or social goals (ability to garden or stand at a cocktail party), with 80% saying that the setting of such goals would be a good way to assess whether the new treatment was working; 91% set treatment goals (an MRI will show less inflammation in the joint), according to Dr. Vibeke Strand.

Most patients (87%) agreed that establishing such targets and achieving them would have a positive impact on their disease management.

Patients’ perceptions of goal setting included:

• I think setting personal and social goals would be of benefit as I can then assess whether my treatment is working or not in a simple to understand way (80% agreed).

• A treatment that works gets me to my personal and social goals quickly (84% agreed).

• If I set myself personal and social goals and achieve them, I would feel positive (87% agreed).

But they expected rapid results. About 81% wanted a new treatment to make them feel better within 3 months, and 56% said they would talk with their physician within less than a month of starting a new treatment if they felt no improvement, said Dr. Strand, adjunct clinical professor in the division of immunology at Stanford (Calif.) University.

A few were willing to give a new treatment longer to produce a benefit, with 20% saying they expected improved signs and symptoms within 3-6 months; only 5% were willing to wait more than 6 months.

Patients are just as impatient with their physicians as with their treatments. A total of 11% cited their physician as the biggest obstacle in controlling RA. Another 54% said that the leading challenge was finding the right treatment, and 16% named lack of education and understanding of RA. The remainder was made up of 11% who said lack of personal resolve was their biggest obstacle, and another 8% listed assorted other issues.

Over half of those surveyed (60%) had not heard of the treat-to-target approach to RA therapy. According to 61%, their physician did not manage their RA with strict goals and timeframes in place. But 62% said that they shared decisions with their physician on how best to treat their RA, Dr. Strand said at the Pespectives in Rheumatic Diseases 2011 meeting, which was sponsored in part by the Skin Disease Education Foundation (SDEF).

This survey was a follow-up to an earlier one of 1,958 women with RA from seven countries, including the United States, which was the first to characterize in detail the impact RA has on the daily lives of women and on their relationships. The survey was conducted on the Internet; all the women had been vetted as having RA of at least 6 months duration and all were 25-65 years of age.

The bottom line from that survey is that well into the era of biologics, women with rheumatoid arthritis report that pain remains a frequent and disabling symptom of their disease. Daily pain was reported by 63% of the women surveyed; 75% said they took pain medication daily, and 87% said they found it important to be able to describe the type and frequency of their RA-associated pain. Overall, 67% of the women reported that they constantly look for new ways to cope with their pain. When asked to describe a "good day with RA," 57% said it was a day free from pain, 58% said it was a day without fatigue, and 29% said it was a day when they were able to do everything easily.

Of the surveyed women, 68% reported that they felt it was necessary to conceal pain from their family and/or coworkers.

Regarding the effects of RA on their activities of daily living, 49% said it was difficult to keep fit, 45% found it difficult to garden, and 67% reported feeling less self-confident at work. Of the women who had been employed full time at diagnosis, 23% of the women had stopped working because of their disease and 27% reported they had cut back their work hours to part time.

The impact of RA extended beyond the workplace: 32% of the women said RA affected their closest relationships, with 55% reporting that they felt less confident in their sexuality; 31% reporting that they found it difficult to explain their sexual needs; of the 611 women who were single, 40% said RA played a role in it being difficult to find a partner.

The overarching weakness of both Internet surveys is the possibility that women with the worst disease were the ones who elected to complete the questionnaire, which may have introduced some bias, Dr. Strand noted.

The survey was funded by UCB, which manufactures Cimzia (certolizumab pegol). Dr. Strand disclosed that she has financial relationships with many companies that make treatments for rheumatoid arthritis, among other things.

SDEF and this news organization are owned by Elsevier.