User login
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
EXPERT ANALYSIS FROM CCR 18