RA Comanagement and the Future
Comanaging RA and its comorbidities is just one of many directions primary care is likely to take. Part 4 of a Special Report.
In the near future, primary care physicians (PCPs) may play an expanded role in rheumatoid arthritis (RA) patient care by comanaging RA and its comorbidities with rheumatologists.[[{"type":"media","view_mode":"media_crop","fid":"56129","attributes":{"alt":"","class":"media-image media-image-right","height":"225","id":"media_crop_8906558343840","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7053","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 5px; float: right;","title":" ","typeof":"foaf:Image","width":"235"}}]]
Comanagement is just one of many emerging issues in RA that may soon affect patient care at the PCP level. In previous articles in this Special Report on Rheumatoid Arthritis in Primary Care, we have addressed the following:
• PCPs may provide more care for patients with RA, an increasingly underserved population.
• PCPs may contribute to improved patient outcomes by recognizing the signs and symptoms of RA early.
• Having made the appropriate diagnosis, PCPs may make more timely referrals to rheumatology.
• PCPs may initiate long-term disease modifying antirheumatic drug (DMARD) therapy earlier in the disease course.
Here we discuss the major areas of comanagement of RA and its comorbidities and the other future directions that RA management is likely to take.
PCPs and rheumatologists working together
The PCP can work with a rheumatologist in comanaging the patient once a diagnosis of RA has been made and DMARD therapy has begun. A critical aspect of comanagement is keeping open lines of communication between the PCP and the consulting rheumatologist.
Next: Comanaging Disease Activity
Following are the major areas of RA comanagement:
Disease activity. Rheumatology typically assesses disease activity. But if disease is worsening, the PCP could ensure follow-up with rheumatology.
A current goal in RA management is treat to target-advancing therapy until a patient reaches a therapeutic goal, typically as measured by a standardized assessment of disease activity (eg, the Disease Activity Score, or DAS) or other standardized measures.1-3 These measures typically include a combination of patient-reported outcomes (PROs), examination findings and, in some cases, biomarkers (eg, the C-reactive protein level).
Some instruments, such as the Simple Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI), rely on PROs and provider assessments and not biomarkers. In addition, there is growing use of biomarker assays, such as the multi-biomarker disease activity test, to assess ongoing disease activity.4
To date, RA disease assessment has been thought to be in the purview of rheumatologists. But with the growing use of PROs in RA5 and in particular methods that can electronically capture a patient’s symptoms, these measurements may become available to PCPs. At the very least, a PCP could notify a patient’s rheumatologist about activity and help adjust medications.
In particular, an understanding is emerging that PROs that can be reported electronically may enhance care with these measures potentially assessed by primary care.
Medication toxicity. A variety of medication toxicities can occur with DMARD therapy, but detailed exploration of these is beyond the scope of this article.
A good rule of thumb: Most patients with RA should have a complete blood count, renal function assessment, and tests for liver injury (eg, transaminases) every 3 months. DMARDs may be held if a significant infection is present. These tests can be performed in a PCP setting.
Before the initiation of most biologic therapies, patients should be assessed for latent tuberculosis through skin or blood testing. PCPs can help rheumatologists in ensuring that this testing is completed in timely fashion.
Next: Comanaging Cardiovascular Disease
Cardiovascular disease. Patients with RA are at increased risk for cardiovascular disease (CVD), and RA is considered an independent risk factor for CVD.6 Perhaps the most important way to minimize risk is to control RA disease activity. However, PCPs can help ensure that CVD risk factors-such as tobacco use, hypertension, diabetes, and cholesterol-are managed appropriately.7
Vaccinations and management of DMARDs during infections. Patients with RA who are receiving DMARD therapy typically need yearly influenza vaccines and vaccines against pneumococcus even if they do not meet age guidelines for these vaccines.8 PCPs can consult CDC guidelines for more information. Live vaccines, such as the Zoster vaccine, may be contraindicated in some patients with RA who are receiving high doses of corticosteroids (> 20 mg/d of prednisone equivalent) or who are receiving biologic therapy.
There are no clear, specific guidelines for management of DMARD therapy during infections. In general, however, if the infection is mild and afebrile and resolves quickly, DMARD therapy can be continued. If there is fever that persists more than 48 hours or the infection requires antibiotic therapy or hospitalization, DMARD therapy should be held and rheumatology consulted.9 The exception is during corticosteroid therapy, which should be continued because of the risk of acute adrenal insufficiency.
Metabolic bone disease. Patients with RA are at increased risk for osteoporotic fractures because of their use of corticosteroids, other risk factors (eg, smoking), and RA’s effect on widespread activation of osteoclasts. PCPs can assist with obtaining bone density measurements and administering therapy (eg, calcium and vitamin D supplementation) and other treatments (eg, bisphosphonates).
Weight loss and smoking cessation. There is increasing evidence that ongoing tobacco use a nd obesity increrase inflammation in RA and may diminish the effectiveness of RA therapies.10,11 It is important for PCPs as well as rheumatologists to work with patients on resolving these issues.
Future directions in RA management for PCPs
In summary, these emerging issues in RA may soon affect patient care at the PCP level:
• Decreases in the rheumatology workforce in the United States may lead to delays in patients being seen by rheumatology, necessitating that PCPs initiate DMARD therapy earlier in the disease course. This is especially important given the growing knowledge that early use of DMARD therapy can result in improved long-term outcomes. Over time, the paradigm may shift enough to involve PCPs.12
• Knowledge is emerging that DMARDs can be tapered or stopped altogether in patients with deep remission in RA.13 The determinants of which patients will be able to taper, and the precise approach to tapering, have yet to be determined, but this aspect of RA care is on the horizon.
• Early approaches to RA prevention may soon affect PCPs. Specifically, in addition to being highly specific for a diagnosis of the presence of currently classifiable RA, elevations in antibodies to citrullinated protein antigens (ACPA) during “preclinical RA” are highly predictive of future development of RA.14
• This information has been used to develop several prevention trials that are under way in the United States and Europe where patients who have serum elevations of various combinations of ACPAs and rheumatoid factor are given DMARD therapy to prevent the future onset of clinically apparent synovitis.15,16 Early data from 1 such study in Europe found that a single dose of the B cell–depleting agent may delay the onset of future RA.17
• More work needs to be done, but in the near future PCPs may participate in identification and treatment of patients who are candidates for prevention. This is much like PCPs participating in CVD prevention through discussion of lifestyle modifications and administration of statins, antihypertensives, and other preventive medications.
• Through appropriate patient evaluation and comanagement, PCPs can help ensure more appropriate referrals and earlier diagnosis and treatment of patients with RA.
Continue to Rheumatoid Arthritis Special Report Post-test
References:
1. Sen D, Brasington R. Tight disease control in early RA. Rheum Dis Clin North Am. 2012;38:327-343.
2. Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012;64:640-647.
3. Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69:631-637.
4. Eastman PS, Manning WC, Qureshi F, et al. Characterization of a multiplex, 12-biomarker test for rheumatoid arthritis. J Pharm Biomed Anal. 2012;70:415-424.
5. van Riel P, Alten R, Combe B, et al. Improving inflammatory arthritis management through tighter monitoring of patients and the use of innovative electronic tools. RMD Open. 2016;2:e000302.
6. Gabriel SE, Crowson CS. Risk factors for cardiovascular disease in rheumatoid arthritis. Curr Opin Rheumatol. 2012;24:171-176.
7. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76:17-28.
8. Friedman MA, Winthrop KL. Vaccines and Disease-Modifying Antirheumatic Drugs: Practical Implications for the Rheumatologist. Rheum Dis Clin North Am. 2017;43:1-13.
9. Dechant SA, Matteson EL. Managing comorbidity risks in rheumatoid arthritis. Curr Opin Rheumatol. 2004;16:177-179.
10. George MD, Baker JF. The Obesity Epidemic and Consequences for Rheumatoid Arthritis Care. Curr Rheumatol Rep. 2016;18:6.
11. Sokolove J, Wagner CA, Lahey LJ, et al. Increased inflammation and disease activity among current cigarette smokers with rheumatoid arthritis: a cross-sectional analysis of US veterans. Rheumatology (Oxford). 2016;55:1969-1977.
12. Espinoza F, Fabre S, Pers YM. Remission-induction therapies for early rheumatoid arthritis: evidence to date and clinical implications. Ther Adv Musculoskelet Dis. 2016;8:107-118.
13. Schett G, Emery P, Tanaka Y, et al. Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis. 2016;75:1428-1437.
14. Deane KD, El-Gabalawy H. Pathogenesis and prevention of rheumatic disease: focus on preclinical RA and SLE. Nature Rev Rheum. 2014;10:212-228.
15. Strategy to Prevent the Onset of Clinically-Apparent Rheumatoid Arthritis (StopRA) https://clinicaltrials.gov/ct2/show/NCT02603146
16. Arthritis Prevention in the Pre-clinical Phase of RA with Abatacept (APIPPRA) ISRCTN No. 46017566 http://www.isrctn.com/ISRCTN46017566
17. European League Against Rheumatism (EULAR) Congress 2016: Abstract OP0182. Presented June 9, 2016. Prevention of clinically manifest rheumatoid arthritis by B cell directed therapy in the earliest phase of the disease (PRAIRI) http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2442
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