What drives your treatment decisions in RA?
Choose all that apply:
A composite score (e.g. DAS, CDAI)
MD score (not a composite such as SJC, MD global)
Other biomarkers/lab test(s)
If you are like most rheumatologists, you don't have a single answer about what drives your treatment decisions. We know that composite scores are often not followed for altering RA treatment and the main reason seems to be doctor discordance with the score – i.e. composite scores may lack face validity such as when a patient rates their disease as high, but the doctor thinks it is inactive.
Matsumoto et al looked at CDAI and decision making for initiating biologics in a large group of Atlantic states practices. If there was CDAI remission, treatment could not be intensified. However, in 3200 RA patients, CDAI was not consistently driving treatment decisions (abstract #504, 506). The bottom line was that there was variability with respect to treatment changes and CDAI scores (except those in CDAI remission, RA treatment was not increased). The problem with scores is that if the doctor doesn't think that the patient has active or smoldering RA, then there is not going to be RA treatment intensification. So, if pain, damage, fibromyalgia, OA, etc are increasing a composite score, we usually ignore it.
Other studies suggested that MRI positivity (abstract #466) or ultrasound findings (#152) in CCP+ patients who had no obvious swollen joints, increased the likelihood that a patient would develop RA, but that is not feasible for most practicing rheumatologists. In addition, it makes me suspect that the patients with joint pain who are CCP+ actually have RA and a physical examination could establish the diagnosis. The test 14-3-3η seems to be associated with a greater chance of X-ray progression if it is positive or becomes positive (data from the ERA Sherbrooke cohort where approximately half are positive at baseline) (#509).
Like most new technologies, it is difficult to know if and where there is added value above routine care, and if certain tests/imaging will make a difference to patients.
So another successful ACR meeting is ending and makes me wonder what I need in order to assess patients adequately.
Dr. Janet Pope is Professor of Medicine at Western University and Division Head of Rheumatology. Dr. Pope's research interests include epidemiologic studies in scleroderma, classification criteria in systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis.View Full Bio