A New Treatment Approach In Rheumatoid Arthritis
A New Treatment Approach In Rheumatoid Arthritis
Jonathan Kay, MD: Hello, I'm Dr. Jonathan Kay, Professor of Medicine at the University of Massachusetts Medical School in Worcester, and Director of Clinical Research in the Division of Rheumatology at UMass Memorial Medical Center also in Worcester. Welcome to this Medscape peer-to-peer discussion from the American College of Rheumatology's 2010 Annual Meeting in Atlanta. Today I'm speaking with Dr. Allan Gibofsky, Professor of Medicine and Public Health at the Weill Cornell Medical College in New York, and Co-Director of the Center for Inflammatory Arthritis at the Hospital for Special Surgery in New York, about new approaches to the treatment of rheumatoid arthritis (RA). Allan, how are you?
Allan Gibofsky, MD: Good Jon, how are you?
Dr. Kay: At this meeting, there are some interesting data that are being presented about new approaches to the treatment of RA, namely treating to target. What can you say about that?
Dr. Gibofsky: The treat-to-target initiative is a concept whose time has come. It basically represents the formalization of some trends that people like you and I have been doing for quite some time. As you know, this began as an initiative under the direction of Dr. Josef Smolen in Austria, with the convening of an international workshop on approaches to the management of RA. That led to a series of papers and presentations about the importance of tight control in RA and what that ought to mean for the practicing rheumatologist.
Dr. Kay: This is sort of like the management of diabetes, where we strive to normalize the hemoglobin A1c [glycated hemoglobin].
Dr. Gibofsky: Exactly right. It means that we need to begin introducing qualitative metrics rather than qualitative "gestalting" into the care of patients because the data have shown that patients who are treated to a target with a specific metric in mind do better than those receiving the ordinary standard of care.
Dr. Kay: In clinical practice in the United States, where we're forced to see patients relatively frequently so that one can accommodate the number of patients who need rheumatologic care, how can a physician quantitatively measure disease activity?
Dr. Gibofsky: There are 2 ways a physician can quantitatively measure disease activity. The first of course is a joint count -- in rheumatology we do joint counts as part and parcel of our stock and trade. But even the rheumatologist who says [he or she is] too busy to do joint counts can always rely on patient report outcomes. Patient report outcomes such as the Health Assessment Questionnaire or HAQ have correlated very nicely, and in some instances even better than the objective metrics, which we think we're performing by doing joint counts and disease activity scores.
Dr. Kay: There are several studies that have been published about treating to target. The TICORA [Tight Control of RA] study from Glasgow, Scotland, the BeSt study from Leiden in The Netherlands, and the CAMERA [Computer Assisted Management in Early Rheumatoid Arthritis] study from Utrecht in The Netherlands, as well as the FIN-RACo [Finnish Rheumatoid Arthritis Combination Therapy] study from Finland. All of these employ joint counts, swollen and tender joint counts, and acute phase reactants as well as patient global assessment to calculate a DAS [disease activity score]. Can these patient-reported outcomes really replace the DAS score in treating to target?
Dr. Gibofsky: The data seem to suggest that patient-reported outcomes correlate so tightly with the objective metrics of a DAS or CDAI [clinical disease activity index] or an SDAI [simplified disease activity index] that they can be used, particularly by the busy rheumatologist. So the objection, "I don't have time to do it," is overweighed and overcome by the fact that you don't have to do it, your patient can do it for you and give you data that are as rewarding and as yielding as anything you're going to do.
Dr. Kay: Are American rheumatologists doing this at this point?
Dr. Gibofsky: I think if you ask American rheumatologists, are you using a metric in your practice, the answer will uniformly be yes because everyone is doing some metric as defined by them -- whether it is a full joint count or a focused joint count, or in some instances a DAS or a CDAI, everyone will tell you they're doing it. The problem is that we have not yet established the link between the metric score and the therapeutic change.
Dr. Kay: What is the goal toward which we should be striving when we're treating to a target in rheumatoid arthritis? Diabetologists have the hemoglobin A1c; what is our goal?
Dr. Gibofsky: Our goal is remission or low disease activity, and the treat-to-target initiative has promulgated as an overarching principle that all patients should be treated to remission wherever possible, but if [that is] not possible [because of] disease chronicity or comorbidity, at the very least we should be aiming for a low disease activity score.
Dr. Kay: How do we get this word out to physicians, to rheumatologists, to primary care physicians, that it's important for our patients to see rheumatologists who will quantitate disease activity?
Dr. Gibofsky: I think there are several approaches. The first is through conferences like this one where there is a special section just dealing with some of the results of the treat-to-target initiative, as well as the treat-to-target rules. The second is a series of regional educational programs that are planned, and the third is that there is going to be an attempt to get patients to ask their doctor, "what is my number." Just as patients demand to know their cholesterol and blood pressure, we would like to get patients to a state of self-empowerment where they ask the doctor, what is my number, whether it's a DAS number or a CDAI number or an HAQ number. What is the number you’re using to drive your therapeutic decisions?
Dr. Kay: European rheumatologists have developed a Website, the METEOR [Measurement of Efficacy of Treatment in the 'Era of Outcome' in Rheumatology] Application [https://www.meteorapplication.com/central/application.html], which is a way in which they can quantitate swollen and tender joints and also allow the patient to enter this portal and fill out a Health Assessment Questionnaire Disability Index before the visit. Is something like this available in the United States?
Dr. Gibofsky: METEOR is certainly available to selected participants who are part of the METEOR constellation if you will. But otherwise we don't yet have that kind of global availability of this kind of patient entry Website. But I think part of the domestic steering committee's plans are to have something up and running by the last quarter of 2011.
Dr. Kay: How can rheumatologists in the United States find out more about treating to target?
Dr. Gibofsky: I think the first thing is to read the original paper in the Annals of Rheumatoid Diseases. The second is, there is a treat-to-target Website, T2Tweblog.com. Viewers can certainly access this for additional information on the treat-to-target initiative and the tools available to help them in their practice.
Dr. Kay: You and I have taken the approach of trying to treat toward a target, whether it be a numeric target or a physical examination where there are no swollen and no tender joints. Why is this not more widely adopted?
Dr. Gibofsky: I think there are several reasons why it's not more widely adopted. The first of course is the time constraints that you alluded to. The second may be the recognition that it may not entirely be necessary because it's only in the last several years that we've had trials like TICORA and CAMERA and DREAM [Dutch Rheumatoid Arthritis Monitoring] that have outlined the fact that this does better. And the third is that since the initial paper has been promulgated in a European journal, it may not have been widely disseminated just yet.
Dr. Kay: This is a very interesting approach and one that certainly seems to benefit our patients. I hope that the treat-to-target initiative will spread information and make metrics or instruments available that can be used by American rheumatologists to provide more effective and rigorous treatment for our patients.
Dr. Gibofsky: Thank you Jon and I'm very grateful that you've given me this opportunity to at least spend a few minutes with your audience to introduce the initiative for those who may not be familiar with it, and to enlist your assistance in carrying it forward.
Dr. Kay: Thank you very much for coming.
Dr. Gibofsky: My pleasure.
Dr. Kay: Thank you for listening to this discussion today. Hopefully, you will come away with some information that will help you in your practice. I'm Dr. Jonathan Kay for Medscape.
Jonathan Kay, MD: Hello, I'm Dr. Jonathan Kay, Professor of Medicine at the University of Massachusetts Medical School in Worcester, and Director of Clinical Research in the Division of Rheumatology at UMass Memorial Medical Center also in Worcester. Welcome to this Medscape peer-to-peer discussion from the American College of Rheumatology's 2010 Annual Meeting in Atlanta. Today I'm speaking with Dr. Allan Gibofsky, Professor of Medicine and Public Health at the Weill Cornell Medical College in New York, and Co-Director of the Center for Inflammatory Arthritis at the Hospital for Special Surgery in New York, about new approaches to the treatment of rheumatoid arthritis (RA). Allan, how are you?
Allan Gibofsky, MD: Good Jon, how are you?
Dr. Kay: At this meeting, there are some interesting data that are being presented about new approaches to the treatment of RA, namely treating to target. What can you say about that?
Dr. Gibofsky: The treat-to-target initiative is a concept whose time has come. It basically represents the formalization of some trends that people like you and I have been doing for quite some time. As you know, this began as an initiative under the direction of Dr. Josef Smolen in Austria, with the convening of an international workshop on approaches to the management of RA. That led to a series of papers and presentations about the importance of tight control in RA and what that ought to mean for the practicing rheumatologist.
Dr. Kay: This is sort of like the management of diabetes, where we strive to normalize the hemoglobin A1c [glycated hemoglobin].
Dr. Gibofsky: Exactly right. It means that we need to begin introducing qualitative metrics rather than qualitative "gestalting" into the care of patients because the data have shown that patients who are treated to a target with a specific metric in mind do better than those receiving the ordinary standard of care.
Dr. Kay: In clinical practice in the United States, where we're forced to see patients relatively frequently so that one can accommodate the number of patients who need rheumatologic care, how can a physician quantitatively measure disease activity?
Dr. Gibofsky: There are 2 ways a physician can quantitatively measure disease activity. The first of course is a joint count -- in rheumatology we do joint counts as part and parcel of our stock and trade. But even the rheumatologist who says [he or she is] too busy to do joint counts can always rely on patient report outcomes. Patient report outcomes such as the Health Assessment Questionnaire or HAQ have correlated very nicely, and in some instances even better than the objective metrics, which we think we're performing by doing joint counts and disease activity scores.
Dr. Kay: There are several studies that have been published about treating to target. The TICORA [Tight Control of RA] study from Glasgow, Scotland, the BeSt study from Leiden in The Netherlands, and the CAMERA [Computer Assisted Management in Early Rheumatoid Arthritis] study from Utrecht in The Netherlands, as well as the FIN-RACo [Finnish Rheumatoid Arthritis Combination Therapy] study from Finland. All of these employ joint counts, swollen and tender joint counts, and acute phase reactants as well as patient global assessment to calculate a DAS [disease activity score]. Can these patient-reported outcomes really replace the DAS score in treating to target?
Dr. Gibofsky: The data seem to suggest that patient-reported outcomes correlate so tightly with the objective metrics of a DAS or CDAI [clinical disease activity index] or an SDAI [simplified disease activity index] that they can be used, particularly by the busy rheumatologist. So the objection, "I don't have time to do it," is overweighed and overcome by the fact that you don't have to do it, your patient can do it for you and give you data that are as rewarding and as yielding as anything you're going to do.
Dr. Kay: Are American rheumatologists doing this at this point?
Dr. Gibofsky: I think if you ask American rheumatologists, are you using a metric in your practice, the answer will uniformly be yes because everyone is doing some metric as defined by them -- whether it is a full joint count or a focused joint count, or in some instances a DAS or a CDAI, everyone will tell you they're doing it. The problem is that we have not yet established the link between the metric score and the therapeutic change.
Dr. Kay: What is the goal toward which we should be striving when we're treating to a target in rheumatoid arthritis? Diabetologists have the hemoglobin A1c; what is our goal?
Dr. Gibofsky: Our goal is remission or low disease activity, and the treat-to-target initiative has promulgated as an overarching principle that all patients should be treated to remission wherever possible, but if [that is] not possible [because of] disease chronicity or comorbidity, at the very least we should be aiming for a low disease activity score.
Dr. Kay: How do we get this word out to physicians, to rheumatologists, to primary care physicians, that it's important for our patients to see rheumatologists who will quantitate disease activity?
Dr. Gibofsky: I think there are several approaches. The first is through conferences like this one where there is a special section just dealing with some of the results of the treat-to-target initiative, as well as the treat-to-target rules. The second is a series of regional educational programs that are planned, and the third is that there is going to be an attempt to get patients to ask their doctor, "what is my number." Just as patients demand to know their cholesterol and blood pressure, we would like to get patients to a state of self-empowerment where they ask the doctor, what is my number, whether it's a DAS number or a CDAI number or an HAQ number. What is the number you’re using to drive your therapeutic decisions?
Dr. Kay: European rheumatologists have developed a Website, the METEOR [Measurement of Efficacy of Treatment in the 'Era of Outcome' in Rheumatology] Application [https://www.meteorapplication.com/central/application.html], which is a way in which they can quantitate swollen and tender joints and also allow the patient to enter this portal and fill out a Health Assessment Questionnaire Disability Index before the visit. Is something like this available in the United States?
Dr. Gibofsky: METEOR is certainly available to selected participants who are part of the METEOR constellation if you will. But otherwise we don't yet have that kind of global availability of this kind of patient entry Website. But I think part of the domestic steering committee's plans are to have something up and running by the last quarter of 2011.
Dr. Kay: How can rheumatologists in the United States find out more about treating to target?
Dr. Gibofsky: I think the first thing is to read the original paper in the Annals of Rheumatoid Diseases. The second is, there is a treat-to-target Website, T2Tweblog.com. Viewers can certainly access this for additional information on the treat-to-target initiative and the tools available to help them in their practice.
Dr. Kay: You and I have taken the approach of trying to treat toward a target, whether it be a numeric target or a physical examination where there are no swollen and no tender joints. Why is this not more widely adopted?
Dr. Gibofsky: I think there are several reasons why it's not more widely adopted. The first of course is the time constraints that you alluded to. The second may be the recognition that it may not entirely be necessary because it's only in the last several years that we've had trials like TICORA and CAMERA and DREAM [Dutch Rheumatoid Arthritis Monitoring] that have outlined the fact that this does better. And the third is that since the initial paper has been promulgated in a European journal, it may not have been widely disseminated just yet.
Dr. Kay: This is a very interesting approach and one that certainly seems to benefit our patients. I hope that the treat-to-target initiative will spread information and make metrics or instruments available that can be used by American rheumatologists to provide more effective and rigorous treatment for our patients.
Dr. Gibofsky: Thank you Jon and I'm very grateful that you've given me this opportunity to at least spend a few minutes with your audience to introduce the initiative for those who may not be familiar with it, and to enlist your assistance in carrying it forward.
Dr. Kay: Thank you very much for coming.
Dr. Gibofsky: My pleasure.
Dr. Kay: Thank you for listening to this discussion today. Hopefully, you will come away with some information that will help you in your practice. I'm Dr. Jonathan Kay for Medscape.
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