Sequencing of Therapy for Rheumatoid Arthritis - Episode 5

RA Disease State Background and Clinical Burden

Derek van Amerongen, MD, MS: There are about 200,000 cases a year of rheumatoid arthritis in the United States. However, I think the disease is far more prominent on the radar screen of managed care because of its cost of therapy. Certainly, when I look at high cost claims lists, which I do multiple times a week, RA is usually, on the pharmacy side, in at least the top 10, possibly the top 15. Certainly, for many employers, it’s one of the top 5 conditions—of course, depending upon their population.

Most of the symptoms and signs of rheumatoid arthritis revolve around things like pain, soreness in the joints, and morning stiffness, particularly mobility and functionality. So, the treatments we’re looking at—the treatments that have evolved over the last 15 or 20 years—really focus on how we make the individual more mobile, better able to function, and better able to accomplish his or her activities of daily living.

Once a patient is diagnosed with rheumatoid arthritis, we do have many tools that we use to help educate the member. Rheumatoid arthritis is a complex condition. It’s a lifelong condition, and certainly, we need to make sure that individuals understand why they have it, what to expect, and the kinds of treatments that are available. We have a combination of nurses, medical directors, and pharmacists who reach out to members, of course, depending upon their level of severity and the type of treatment they’re getting. But we think about getting the member/consumer in the center of that interaction, so that they really are part of designing the treatment plan and making sure that the treatment plan is going to be effective. That’s really critical because, remember, treating arthritis as a lifelong condition involves much more than just drugs. It really involves lifestyle management, understanding the course of the disease, and making sure that the individual understands the importance of therapy so that he or she can be maximally adherent and compliant.

Like many if not most conditions, early diagnosis and treatment of rheumatoid arthritis has significant advantages. Certainly, there are some conditions where early treatment really won’t make a big difference in the long run. But when you look at the pathophysiology of rheumatoid arthritis and what leads to the symptoms of pain, lack of mobility, and functionality, they relate very heavily to the buildup of fibrosis and the problems that people experience with their joints. So, the point is that treating it earlier will, ideally, head off some of that, or at least attenuate the development of the joint stiffness, soreness, and problems with mobility. More and more, the emphasis is on how we can understand who is going to be benefiting from treatment at an earlier stage, and then, once those people are identified, getting them into the right treatment as quickly as possible.

The American College of Rheumatology guidelines, or the ACR guidelines, are important to managed care. We want to make sure that the policies we develop are evidence-based and that we’re sharing information not only with the physicians who treat our members but also our members. More and more, I think individuals understand that there are well-accepted ways of treating conditions, especially long-term conditions like rheumatoid arthritis. And so, making sure that there’s transparency around that is a very important piece. As we develop our medical policies, we want to be sure that they are reflecting the current standard of care and really are in line with what the expert associations in the United States recommend.

One of the biggest challenges that we have, as we develop our medical policies and try to understand how various treatments fit into the treatment algorithm as laid out in the ACR guidelines, is understanding how drugs compare head-to-head. That has been a challenge, I think, for decades. There are very few true head-to-head clinical trial data available. Certainly, as a new drug comes to market, it has to have data versus placebo. That’s what the FDA requires. But the challenge for the clinician in the office is that he or she has been using drug A, and now there’s drug B—how does he or she compare one to another, in terms of moving patients towards either one or the other?

That’s a challenge for clinicians who want to make sure that they’re giving their patients the best treatments, but at the same time, do they take a risk on a new drug that they’re not familiar with? Or do they use the drug that they’ve had in their armamentarium for many years, even though they know that it’s not perfect and has its limitations? As we develop more head-to-head trial data and as they become available—and I also think that as it becomes an expectation, it’ll be easier to make those clinical assessments—it’ll be easier for managed care to develop formularies that really focus on the drugs that are going to be delivering the optimal clinical benefit. And, of course, it will also help us understand value—value being that interplay between clinical benefit and cost.