Out-of-Office Rheumatoid Arthritis Monitoring

Pharmacists helping patients evaluate the effectiveness of their RA therapy is likely a better solution for reducing office visits than patient self-monitoring.

I was recently asked to join a colleague on a call with his co-workers to share my thoughts on rheumatoid arthritis (RA). Much of the conversation focused on quality of care and measuring the effectiveness of biologic and targeted disease-modifying antirheumatic drugs (DMARDs) such as adalimumab (Humira), etanercept (Enbrel), and tofacitinib (Xeljanz).

Around the same time, a study sought to determine whether RA patients who self-monitor their disease could be as effective as patients under standard care, primarily in terms of health care usage.1

Patients in the intervention group were trained to interpret their laboratory results and take action (eg, schedule an appointment) when they were out of range. Those who failed to take action when lab values prompted serious concerns were followed up by a nurse who also received the results.

In the study, self-monitoring RA patients had fewer visits with a clinical nurse specialist (CNS), rheumatologist, and general practitioner. However, this difference was only significant for CNS visits, and there were no significant differences between trial arms in terms of clinical outcomes.

How would I have conducted this study? In short, I would have involved the pharmacist.

The original goal of the research may have been to determine self-monitoring impact office visits, but patients are not always willing or able to monitor their disease independently. In fact, nearly one-third of RA patients assessed for eligibility declined to participate in the study.

Regardless of ability or willingness to self-monitor, patients do routinely receive their RA medications from a pharmacy, which presents the perfect opportunity to speak with a pharmacist and jointly assess the effectiveness of their therapy.

Just as they have shifted vaccination settings, pharmacists can reduce the office burden for RA patients and other populations. But how can a pharmacist tell whether a patient is getting better or worse?

The American College of Rheumatology (ACR) has several recommended disease activity assessment tools.2 Some require provider input, such as the Physician Global Assessment (PGA), or lab values like acute phase reactants (eg, ESR, CRP) that patients in the aforementioned study independently interpreted.

More practical assessment tools that can be used in pharmacies rely only on patient-reported data. The 3 included in the ACR recommendations are versions I and II of the Patient Activity Scale (PAS and PAS-II) and the Routine Assessment of Patient Index Data with 3 measures (RAPID-3). All of them use a version of the Health Assessment Questionnaire (HAQ).

The PAS uses the original HAQ and is estimated to take a patient less than 3.5 minutes to complete. The PAS-II uses the HAQ-II and is estimated to take the patient less than 1.5 minutes. The RAPID-3 uses the Multidimensional version (MDHAQ) and is also estimated to take less than 1.5 minutes.

Some say that the HAQ-II has better question spacing and a lesser floor effect than the the MDHAQ. In addition to the HAQ, a numerical rating scale for pain and Patient Global Assessment (PtGA) are components of all 3 assessments.3 In my opinion, the PAS-II and RAPID-3 are the most suitable assessments for pharmacy use.

Completion of these assessments allows scoring of a patient’s disease activity. Using these scores, a pharmacist can determine the severity of the disease from remission to low, moderate, or high (Table).

Table. Disease activity cutoffs for each ACR-recommended patient-driven composite tool for disease activity measure

Disease activity measure

Scale

Remission

Low/minimal

Moderate

High/severe

PAS

0-10

0.00-0.25

0.26-3.70

3.71 to <8.0

8.00-10.00

PAS-II

0-10

0.00-0.25

0.26-3.70

3.71 to <8.0

8.00-10.00

RAPID-3

0-10

0-1.0

>1.0 to 2.0

>2.0 to 4.0

>4.0 to 10

Adopted from Anderson et al.

The primary goal of RA treatment is to achieve low disease activity or remission.4 Therefore, completing these assessments with patients at times that align with the ACR’s treatment guidelines can help determine the effectiveness of a DMARD and support the patient’s subjective assessment with an objective score.

If the information supports that the medication is ineffective, then the pharmacist can work with the patient and prescriber to determine the cause (eg, non-adherence) and decide whether switching to another therapy is warranted. Conversely, positive results can be shared with the patient to reinforce the effectiveness of the DMARD.

Pharmacists helping patients evaluate the effectiveness of their RA therapy is likely a better solution for reducing office visits than patient self-monitoring. Pharmacists can also help the prescriber keep abreast of the patient’s status and improve the chances of successful treatment.

References:

1. McBain H, et al. A patient-initiated DMARD self-monitoring service for people with rheumatoid or psoriatic arthritis on methotrexate: a randomised controlled trial. Ann Rheum Dis. 2015 Aug 19. pii: annrheumdis-2015-207768. doi: 10.1136/annrheumdis-2015-207768. [Epub ahead of print].

2. Anderson J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012 May;64(5):640-7.

3. Pincus T, et al. Development of a multi-dimensional health assessment questionnaire (MDHAQ) for the infrastructure of standard clinical care. Clin Exp Rheumatol. 2005 Sep-Oct;23(5 Suppl 39):S19-28.

4. Singh JA, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res. 2012;64(5):625‐39.