Navigating Treatment Decisions for Rheumatoid Arthritis: Key Factors to Consider

Announcer:
You’re listening to Living Rheum on ReachMD. On this episode, we’ll hear about challenges in treating rheumatoid arthritis patients with Dr. Robin Dore. She’s a board-certified rheumatologist and an Invited Lecturer at the University of California, Irvine in the Division of Rheumatology. Let’s hear from Dr. Dore now.

Dr. Dore:
Some patients will present with a lot of pain and a little bit of swelling, and other patients come in with lots of swelling and very little pain. So when we’re trying to figure out what medicine to use for them, we need to look at the different characteristics of their disease. So if a patient has difficulty breathing, maybe their lungs are affected by their rheumatoid arthritis. If they have a rash, maybe they have a vasculitis related to their rheumatoid arthritis. So because the presentation is so different, that makes it difficult because there’s no one treatment for all.

The other problem is that patients come in with a pre-existing bias, and so they’ll say, “I don’t want to take that thing that I see advertised on TV,” or they’ll say, “I don’t want to take this thing that my neighbor next door takes,” so very often, they’ll come in with this attitude of “I don’t want to take anything.” Now, I had one patient who came in and said, “Give me anything you want to. I want to get better.” And I’m immediately thinking of all the potential side effects of the medicine, and that puts me in a spot. The easiest people to treat are those who have a friend or relative who has rheumatoid arthritis. They know how disabling untreated rheumatoid arthritis can be, so it’s a lot easier to go through the different treatment regimens with them because they want to take something that’s going to prevent them from being like their neighbor or their relative.

I talk to patients about the fact that, in life, everything has a risk or a benefit. So when I’m talking to them about potential treatments, that’s really what I start out with. So we start out with the risk-benefit, and then we talk about, “Well, rheumatoid arthritis can actually cause an early death because it can cause coronary heart disease and inflammation in the lungs, and that can cause you to have trouble breathing and perhaps an early death.” So once they realize it’s not just arthritis, then they’re much more willing to at least consider taking a medication that has some potential risk. And I always try to follow the American College of Rheumatology guidelines, so when I’m talking to patients, I’m saying, “My recommendations are data-based, and this is what the data suggests, and this is what I’d really like to talk to you about.”

When we’re talking about switching medications, the American College of Rheumatology recommends that we wait at least three months for a certain treatment regimen to be effective. Some of the patients just can’t wait that long, and they’ll come in and they’ll send me a message at eight weeks and say, “Dr. Dore, this is not working. I just can’t take this.” And then I’ll have them come in, and we’ll talk about a different alternative. But what the American College of Rheumatology says is after a three-month period of time, if the patient hasn’t gone from either high disease activity to moderate disease activity or moderate disease activity to low disease activity, then we’re supposed to talk to them about changing medications.

Now, certainly, if a patient has an adverse event from a medicine, then we change them right away; otherwise, I’m going to wait that 8 to 12 weeks and talk to them about how my recommendations are data-based and that the American College of Rheumatology says if they’re on this drug and it hasn’t worked, to go to a drug in a different class. Now, sometimes the patients don’t want to change, so they’ll have gone from high disease activity to moderate disease activity, and they’re so much better. And so my conversation has to be, “But you could be even better. And I know it’s risky and there’s no guarantee that treatment will work, but I want you to think about changing to a different class of medicine that, hopefully, will work better.” And someone will say, “I’m happy with the way that I am.” I say, “Well, let’s revisit that next time you come in.” So it’s an ongoing conversation.

Announcer:
That was Dr. Robin Dore talking about difficulties in managing patients with rheumatoid arthritis. To access this and other episodes in our series, visit Living Rheum on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!