Madelaine Feldman, MD: Strategies, Hurdles in Rheumatoid Arthritis Treatment

Most rheumatologists follow a fairly standard method for identifying the best treatment for patients with rheumatoid arthritis. However, these providers face certain challenges, including the comorbidities that patients may have and the limits of formularies.

In an interview with MD Magazine®, Madelaine A. Feldman, MD, FACR, shared about the current standard treatment protocol for rheumatoid arthritis as well as some of the challenges that remain for health care providers in the area of rheumatology.

Feldman is President of the Coalition of State Rheumatology Organizations, Chair of Alliance for Safe Biologic Medicines, and on the Board of Directors for Rheumatology Alliance of Louisiana.

Is there currently a standard treatment for rheumatoid arthritis?

What are some of the biggest hurdles to optimizing arthritis care?

What challenges do formularies present to arthritis care?

[Transcript has been edited for clarity.]I think most rheumatologists do follow the use of non-biologic and simple DMARDs (disease-modifying antirheumatic drugs) of which the gold standard is methotrexate. One thing that I think is being utilized more—which I think is a good thing—is the parenteral use of methotrexate, the subcutaneous administration where you have a better idea of absorption and levels. And at that point the American College of Rheumatology guidelines really offer a wide choice for the physician as the next level. Patients that have not—for whatever reason have not—responded to methotrexate, you can use a different disease modifying agent, leflunomide. For those very mild cases sometimes we do use hydroxychloroquine with steroids being used as a flare, but very quickly we've decided in treat to target if after 3 months the patient does not, I would like to say get to the status of remission, it's important to change or add therapy. So, usually the next set is the biologics and now the non-biologic JAK inhibitors. So, that pretty much has been the standard of treatment and then following those patients—if in 3 to 4 months they have not improved and reached what we call a low disease activity state, you should change or add. I think most rheumatologists are following that treat to target algorithm.I think probably one of the things that we've made note of over the last 5 years or so are the comorbidities that go along with the autoimmune diseases—whether it's rheumatoid arthritis, psoriasis, psoriatic arthritis, or lupus. We now know that cardiovascular disease is a very important comorbidity and having one of these diseases increases your risk of heart attack. So, in addition to treating the joints or the skin or the kidneys, we've had to always be concerned obviously about the high blood pressure and the cholesterol, but we have to really be keenly aware of making sure that the other risk factors for cardiovascular disease are not a part of what's going on with the patient. Because what good is that to make all of their joints feel good if they have a stroke? So, I think that's been you know probably something—one of the hurdles—I wouldn't call it a hurdle, but at least certainly another consideration.The idea of shared decision-making is a really good thing, but there are some obstacles to the shared decision-making. Probably one of the things that most prescribers bemoan is that you'll sit and spend all of this time and you talk about all of the different options that we have now for treating, for example rheumatoid arthritis, and then you're up against a formulary wall where you can't use the medication that you think is best for the patient. So, I think that probably is another important obstacle.