Musings from EULAR 2016: What Will (or Might) and What Will Not Change my Practice

What will (or might) change my practice:

• I really may consider a COBRA type approach to treatment in ERA – that is to say, I will likely keep my practice of triple therapy but consider a high-dose, front end load of steroids (many COBRA strategies presented at this meeting – #OP0262, #THU0104)

• I may use more subcutaneous methotrexate since in the CATCH cohort it seemed to reduce the need for subsequent treatment with advanced therapeutics and prolong the time to obtaining a biologic (Gottheil S, #OP0179).

• I can now tell patients that cold (and dampness) can make their RA feel worse (Mandl P et al. #FRI0092).

What I am not sure of for practice:

• I don't know the best initial treatment in ERA so despite the new EULAR guidelines presented on Saturday and the ACR 2015 guidelines that both suggest initiation of monotherapy with methotrexate, I still tend to prefer combination treatment at onset due to RCTs showing a better response of combinations vs. MTX monotherapy.

• There was a session on reporting and interpreting patient reported outcomes (Friday) and although I often have my assessment of disease activity 'trump' what the patient tells me if there is discordance (i.e. misattribution of disease activity from the patient's perspective) but in general if the patient has poor patient-reported outcomes, they don't do well overall so treating the comorbidities that affect PROs and educating the patient about attribution may help converge global assessments over time. However, I think I do this (somewhat) currently.

What won't change my practice:

• I will continue to recommend HZ vaccination to patients who meet the indications for vaccination. Steroids are the biggest risk factor in our inflammatory / autoimmune patients (as seen in Rhumadata, Haroui B et al. EULAR 2016, #FRI0120).

• I will continue to be skeptical about the added benefit of ultrasound for routine use in RA (negative study from ERA RCT [Haaversham, ARCTIC], another negative study (#OP0181 POET US) and one with borderline results (#000124 Glimm).

• I will continue to use more options (i.e. new mechanisms of action) for my patients with RA who aren't doing well on current treatment (lots of abstracts on JAK inhibitors and other MOAs).

• I will continue to pay attention to cost of treatment preferring less expensive treatment strategies where possible (see data on Improved – aiming for deep remission, intervening with steroids for patients to get out of a flare, using biosimilars when considering biologic initiation, etc). Cost of strategies was presented where COBRA-light costs less in the CARERA study (De Cock D). So specific intial strategies in ERA have a long-lasting cost benefit.

• Treatment with biologics by ACPA status. I am not convinced that I should preferentially choose an advanced therapy post traditional DMARDs by ACPA status despite data suggesting that abatacept has a better response than TNFi treatment in RA if ACPA is positive. I will not repeat ACPA to see pre-prescribing what the status currently is. I think further data are needed (Harrold LR et al. EULAR 2016, #FRI0205).

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