Counseling Points - November 2008 - (Page 8)

Table 4. Treatment of RA with Conventional DMARDs12 DMARD Hydroxychloroquine Leflunomide Methotrexate Minocycline Sulfasalazine Dual Therapy Methotrexate plus hydroxychloroquine Methotrexate plus leflunomide Methotrexate plus sulfasalazine Triple Therapy Methotrexate plus sulfasalazine plus hydroxychloroquine Any Poor prognosis/moderate to high activity Any ≥6 months Any Any/moderate to high activity Any/high activity Any prognosis/high activity Disease Duration ≤24 months Any Any <6 months Any Prognosis & Disease Activity Without poor prognosis/low activity Any/any Any/any Without poor prognosis/low activity Without poor prognosis/any activity demonstrate a ≥20% improvement in the number of swollen and tender joints plus improvement in three of five of the additional measures. An ACR 50 or ACR 70 demonstrates a 50% or 70% improvement, respectively, in the joint count plus improvement in three of the five additional measures.2 cline is appropriate for individuals with low disease activity and short disease duration without poor prognostic features. The dual-DMARD combination methotrexate plus sulfasalazine is recommended in patients with high disease activity and any prognostic features, regardless of disease duration. Methotrexate plus leflunomide may be used in patients with high disease activity and any disease duration.12 In addition, triple DMARD combinations are typically recommended for all patients with poor prognostic features of RA and moderate or high levels of disease activity, regardless of disease duration.12 It is important that RA patients see their rheumatologist regularly to assess disease activity and determine if treatment adjustments are needed.2,12 Accordingly, patients with RA may require a switch in therapy or a combination of drugs in order to control symptoms. For example, even though methotrexate has a long-standing record of effectiveness and is standard treatment for RA, many patients may experience adverse events or loss of efficacy with this agent. 15 The ACR states that if individuals experience Identifying and Managing Treatment Nonresponders RA symptoms and disease activity vary from patient to patient. Thus, response to RA treatments also varies considerably by individual.12 The new ACR recommendations provide a guide for the use of nonbiologic and biologic DMARDS for RA patients who are starting or who have failed DMARD treatment (Table 4).12 In general, monotherapy with the nonbiologic DMARDs leflunomide, methotrexate, or sulfasalazine is recommended for all disease durations and for all degrees of disease activity.12 Hydroxychloroquine is recommended for patients with low disease activity and disease duration of ≤24 months without poor prognostic features, while minocyCOUNSELING POINTS™ 8

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Counseling Points - November 2008

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