2020 Symposia Series 2 Rheumatoid Arthritis: Best Practices in - - PowerPoint PPT Presentation

2020 Symposia Series 2

Rheumatoid Arthritis: Best Practices in Diagnosis and Management in the Era of Novel Agents

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Learning Objectives

• Assess patients for signs and symptoms of rheumatoid arthritis (RA)
• Identify novel therapies for RA and their appropriate use in clinical

practice

• Evaluate patients with RA for extra-articular manifestations and

comorbidities

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• 1.5 MILLION ADULTS in the

United States have RA

• 3x as many women as men

Dadoun S, et al. Joint Bone Spine. 2013;80:29-33; Gonzalez A, et al. Arthritis Rheum. 2007;56:3583-3587; Humphreys JH, et al. Arthritis Care Res (Hoboken). 2014;66:1296-1301; Myasoedova E, et al. Arthritis Rheum. 2010;62:1576-1582; Sokka T, et al. Arthritis Res Ther. 2010;12:R42.

Prevalence of RA

= 10,000 people

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Environmental and Genetic Risk Factors for RA

• RA is thought to be

associated with: ‒ Genetics ‒ Female sex

*Gut dysbiosis in patients with RA may result from an increased abundance of certain rare bacterial lineages. Managing RA by manipulating the gut microbiota is a new area of research. Abella V, et al. Life Sci. 2016;157:140-144; Chen J, et al. Genome Med. 2016;8:43; Yarwood A, et al. Rheumatology (Oxford). 2016;55:199-209.

Genetic background Environmental factors (eg, smoking, periodontitis, pollution, gut microbiota*, others) Asymptomatic Outcomes (disability, joint surgery) Intermittent mono- or oligo- arthritis Persistent symmetric polyarthritis Clinical (inflammation) Preclinical (autoimmunity)

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Pathogenesis of RA

Anti-CCP = antibodies to citrullinated peptide; Cit = citrullinated peptide; DC = dendritic cell; MØ = macrophage; RF = rheumatoid factor. Adapted from: Smolen JS, et al. Nat Rev Drug Discov. 2003;2:473-488.

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Importance of Early Diagnosis in RA

• RA is progressive, not benign
• Structural damage and disability occur within first 2 to 3 years of disease
• Slower progression of disease is linked to early treatment with DMARDs
• Once bone and cartilage are damaged, they never return to normal

Smolen JS, et al. Ann Rheum Dis. 2010;69:631-637; Smolen JS, et al. Ann Rheum Dis. 2017;76:960-977.

Disease

• nset

Optimal window of opportunity

• Severe functional decline
• Radiographic damage
• Work disability
• Premature death

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Radiographic Progression of RA

1987

Radiographs courtesy of Brian Peck, MD and Rick Pope MPAS, PA-C.

2007

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Radiographic Progression of RA (cont’d)

20 16 12 8 4 5 10 15 20

Count Disease Duration (Years)

Wolfe F, et al. Arthritis Rheum. 1998;41:1571-1582.

Joint-space narrowing count Erosion count Deformity count

• Joint-space narrowing

and erosion are seen in up to two-thirds of patients within the first 2 to 5 years of disease

• Irreversible damage

can develop within months of RA onset

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Articular Manifestations of RA

• Swelling, tenderness, warmth, and painful motion
• Morning stiffness

‒ May also appear after brief periods of inactivity

• Inflammation of synovial joints
• Joint and periarticular tissue destruction
• Joints most often involved:

‒ Proximal interphalangeal (PIP) ‒ Metacarpophalangeal (MCP) ‒ Wrists, elbows, shoulders, knees, ankles, and subtalar and metatarsophalangeal (MTP) joints

PIP Swelling

Haudenschild DR, et al. In: Kelley’s Textbook of Rheumatology, 9th ed. 2012. Image from: Ostendorf B, et al. Ann Rheum Dis. 2005;64:501-502.

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Early RA in a Young Woman

Image courtesy of Lester Miller, MD.

• Symmetrical joint swelling in

the hands

• Swelling prominent in the PIP

joints and in the left thumb interphalangeal (IP) joint

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Early RA in a Young Woman

Image courtesy of Lester Miller, MD.

• Swelling is particularly

prominent in the MTP joints, especially the 1st and 5th MTPs

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Case Study: Tara, a 42-year old woman

• Presents with a 3-month history of pain and stiffness in hands and right knee, as well as

chronic fatigue

• Complains of morning stiffness >30 minutes and increased pain at work as a post office

mail sorter

• 2 MCP joints (left hand) and 1 PIP joint (right hand) are visibly swollen
• Height: 5 ft 2 in; weight: 150 lb; BMI: 27.4 kg/m2; BP: 123/82 mm Hg
• Previous clinician had diagnosed OA, prescribed NSAIDs, and suggested diet and exercise

to lose weight

• Mother had RA
• Smoking status: 1/2 pack per day
• Alcohol consumption: drinks socially

NSAID = nonsteroidal anti-inflammatory drug; OA = osteoarthritis.

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Squeeze Test Assessment

• Squeeze test allows for

quick clinical evaluation

• f MTP/MCP joints
• Tenderness identified

by gentle palpation of the joints

Emery P, et al. Ann Rheum Dis. 2002;61:290-297.

\

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Common Disorders to Consider in the Differential Diagnosis of Arthritides

RA OA PsA Gout Peripheral disease Symmetric Asymmetric Asymmetric — Axial joint/spondylitis No No Yes Less often Stiffness Morning/ immobility With activity Morning/ immobility Yes Enthesitis No No Yes Yes Nail lesions No No Yes No Psoriasis Uncommon Uncommon Yes Uncommon Female:male ratio 3:1 Hand/knee > in women 1:1 —

PsA = psoriatic arthritis. Gottlieb A, et al. J Am Acad Dermatol. 2008;58:851-864; Mease PJ, Armstrong AW. Drugs. 2014;74:423-441.

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Progression of Joint Damage in Subgroups

• f Early RA

Radiographic Joint Damage Score Time (Years)

Anti-CCP– Anti-CCP+

Key Biomarker in RA: Anti-CCP

Van der Helm-van Mil AH, et al. Arthritis Res Ther. 2005;7:R949-R958. 2 4 10 20 30 40

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Case Study: Tara’s Lab and Imaging Results

ANA = antinuclear antibodies; ESR = erythrocyte sedimentation rate.

• ANA: 1:60 (positive)
• Anti-CCP: >250 u/mL (positive)
• CRP: 20.5 (positive)
• ESR: 48 mm/hr (positive)
• RF: 87 U/mL (positive)
• Uric acid: 4.5 mg/dL (normal)
• X-rays of hands and feet: normal

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Case Study: Next Steps

• Based on the history, physical exam, lab tests, and x-rays, you suspect an

inflammatory arthritis, most likely RA

• You refer Tara to a rheumatology specialist for confirmation and

management

• Specialist performs a full workup and concludes that Tara has early,

moderately active RA

• Specialist discusses with Tara the advantages of treating RA aggressively

to achieve clinical remission (or at least low disease activity [LDA])

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Treatment Strategy for RA: Treat-to-Target Task Force Algorithm

Active RA

Clinical remission (eg, DAS) Clinical sustained remission

LDA Sustained LDA MAIN TARGET ALTERNATIVE TARGET

• Measure disease

activity every 1-3 months

• Adapt therapy

accordingly

• Measure disease

activity ~3-6 months

• Adapt therapy if

state is lost

DAS = disease activity score. Task Force definitions: active RA = DAS44 score >2.4; remission = absence of signs and symptoms of significant inflammatory disease activity; sustained remission = remission sustained for 3-6 months; LDA = DAS44 score ≥1.6 to ≤2.4; sustained LDA = LDA sustained for 3-6 months. Adapted from: Smolen JS, et al. Ann Rheum Dis. 2010;69:631-637. Grigor C, et al. Lancet. 2004;364:263-269.

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Criteria for Clinical Remission

*Patient Global Assessment = patient self-reporting questionnaire. ACR = American College of Rheumatology; EULAR = European League Against Rheumatism; SDAI = Simplified Disease Activity Index; SJC = swollen joint count; TJC = total joint count. Felson DT, et al. Ann Rheum Dis. 2011;70:404-413.

• Definition: absence of signs and

symptoms of significant inflammatory disease activity

• According to ACR and EULAR,

remission is achieved when: ‒ TJC, SJC, CRP level (in mg/L) and Patient Global Assessment* (on a scale of 0-10 cm) are all ≤1; or ‒ SDAI score is ≤3.3

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• MTX is the anchor drug

for treatment of RA

The ACR Guideline for Early RA: How it Applies to Tara

Combination traditional DMARDs or TNFi +/- MTX or non-TNF biologic +/- MTX See established RA algorithm

Treat to target

Moderate or high disease activity Low disease activity DMARD monotherapy DMARD monotherapy Moderate or high disease activity Moderate or high disease activity

Strong recommendation Conditional recommendation

Tara

DMARD-naïve early RA

MTX = methotrexate; TNFi = tumor necrosis factor inhibitor. Singh JA, et al. Arthritis Care Res (Hoboken). 2016;68:1-25.

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Case Study: Tara’s Management Plan

• Tara is prescribed MTX (20 mg/week orally) and folic acid
• She is counseled on:

‒ Need for reliable contraception ‒ No alcohol within 24 hours of MTX dose ‒ Smoking cessation ‒ Diet and exercise to reduce weight

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Case Study: 3-month Follow-up

• Tara complains that she’s had only minimal improvement in symptoms

and that she has some nausea, vomiting, and hair loss from the MTX

• Other findings

‒ Has reduced alcohol intake as instructed ‒ Has lost 5 lbs ‒ Hasn’t stopped smoking ‒ Still has 2 swollen MCP joints and knee pain

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• MTX is the anchor drug

for treatment of RA

Where Tara Is Now in the ACR Guideline for Early RA

Strong recommendation Conditional recommendation

Tara

Singh JA, et al. Arthritis Care Res (Hoboken). 2016;68:1-25.

Combination traditional DMARDs or TNFi +/- MTX or non-TNF biologic +/- MTX See established RA algorithm

Treat to target

Moderate or high disease activity Low disease activity DMARD monotherapy DMARD monotherapy Moderate or high disease activity Moderate or high disease activity

DMARD-naïve early RA

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*Contraindicated prior to and during pregnancy and breastfeeding, as well as in patients with active bacterial infection, active herpes zoster virus infection, active or latent tuberculosis, or acute or chronic hepatitis B or C. AE = adverse event. Hydroxychloroquine [prescribing information]. Sanofi-Aventis; 2019; Minocycline [prescribing information]. Medicis; 2011; Rigby WF, et al. Int J Rheumatol. 2017:9614241; Saag KG, et al. Arthritis Rheum. 2008;59:762-784; Singh JA, et al. Arthritis Care Res (Hoboken). 2012;64:625-639; Singh JA, et al. Arthritis Care Res. 2016;68:1-25; van Vollenhoven RF. Nat Rev Rheumatol. 2009;5:531-541.

Conventional Synthetic DMARDs for RA

Agent Risks and AEs Routine Laboratory Monitoring Hydroxychloroquine Nausea, vomiting, diarrhea, rash/hyperpigmentation, cytopenia, myopathy, cardiac dysrhythmias, retinopathy None Leflunomide* Hypertension, hepatotoxicity, myelotoxicity, severe diarrhea Complete blood count, liver transaminase levels, and serum creatinine levels Methotrexate* Hepatotoxicity, fibrosing alveolitis, myelotoxicity,

• pportunistic infection, teratogenicity, nausea, vomiting

Minocycline Nausea, vomiting, diarrhea, dyspepsia, dizziness, skin rash, teratogenicity Sulfasalazine Hepatotoxicity, hypersensitivity reactions, myelotoxicity, reversible male infertility

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aContraindicated in patients with active bacterial infection, active herpes zoster virus infection, active or latent tuberculosis, or acute or chronic hepatitis B or C. bLive vaccines should be avoided in patients currently taking immunosuppressive agents or likely to start immunosuppressive therapy within 6-12 weeks.

ABA = abatacept; ADA = adalimumab; CTZ = certolizumab pegol; ETN = etanercept; GLM = golimumab; IFX = infliximab; RTX = rituximab. Furst DE, et al. Ann Rheum Dis. 2012;71(Suppl 2):i2-i45; Saag KG, et al. Arthritis Rheum. 2008;59:762-784; Singh JA, et al. Arthritis Care Res (Hoboken). 2012;64:625-639; van Vollenhoven RF. Nat Rev Rheumatol. 2009;5:531-541.

Class (Agent)a,b Risks and AEs Routine Laboratory Monitoring TNF blockade Adalimumab Certolizumab pegol Etanercept Golimumab Infliximab Injection site reactions, infections, demyelinating disease exacerbation or new onset, heart failure worsening or new onset, lymphoma, melanoma ADA: None CTZ: None ETN: None GLM and IFX: Liver enzymes, neutrophils and/or platelets, and serum creatinine T-cell costimulation blockade Abatacept Infusion reactions, infections ABA: None B-cell depletion Rituximab Infusion reactions, infections RTX: Liver enzymes, neutrophils and/or platelets, and serum creatinine

Biologic and Targeted Synthetic DMARDs for RA

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aContraindicated in patients with active bacterial infection, active herpes zoster virus infection, active or latent tuberculosis, or acute or chronic hepatitis B or C. bLive vaccines should be avoided in patients currently taking immunosuppressive agents or likely to start immunosuppressive therapy within 6 to12 weeks.

BCB = baricitinib; IL = interleukin; JAK = Janus kinase; SRB = sarilumab; TCZ = tocilizumab; TOF = tofacitinib; UPA = upadacitinib; URI = upper respiratory infection. Baricitinib [prescribing information]. Lilly USA; 2019; Furst DE, et al. Ann Rheum Dis. 2012;71(Suppl 2):i2-i45; Saag KG, et al. Arthritis Rheum. 2008;59:762-784; Sarilumab [prescribing information]. Sanofi-Aventis; 2018; Singh JA, et al. Arthritis Care Res (Hoboken). 2012;64:625-639; Upadacitinib [prescribing information]. AbbVie Ireland NL B.V; 2019; van Vollenhoven RF. Nat Rev Rheumatol. 2009;5:531-541.

Class (Agent)a,b Risks and AEs Routine Laboratory Monitoring IL-6 receptor blockade Sarilumab Tocilizumab Infusion reactions, infections, neutropenia, reduced platelet counts, elevated liver enzymes, elevated lipids, GI tract perforation SRB: Liver enzymes, neutrophils and/or platelets; infection, tuberculosis TCZ: Lipids, liver enzymes, neutrophils and/or platelets JAK inhibition Baricitinib Tofacitinib Upadacitinib URIs, shingles, headache, diarrhea, nasopharyngitis, lymphoma, nonmelanoma skin cancer, GI tract perforation, lipid abnormalities BCB: Infection, tuberculosis, hepatitis B TOF: Lipids, liver enzymes, neutrophils and/or platelets UPA: Lipids, liver enzymes, neutrophils, hemoglobin, lymphocytes IL-1 receptor blockade Anakinra Injection site reactions, infections, neutropenia None

Biologic and Targeted Synthetic DMARDs for RA (cont’d)

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After 6 Months, Tara’s RA Remains Moderately Active

• After Tara’s last visit, the specialist

⎻ Switched her from oral to SC MTX to address her nausea ⎻ Added the TNF inhibitor adalimumab ⎻ Continued folic acid

• Tara is still unsuccessful in attempts to quit smoking
• She continues to work toward losing weight with diet and exercise
• However, after 3 months of MTX + adalimumab therapy, Tara still:

⎻ Has morning stiffness and pain that impair her ability to work ⎻ Feels fatigued ⎻ Has problems tolerating MTX, even in SC form

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Case Study: Adjusting Treatment

• To reach the target of clinical remission for Tara, the specialist:

‒ Discontinues adalimumab and MTX ‒ Switches her to the IL-6 inhibitor sarilumab

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Adjusting Treatment to Achieve the Therapeutic Target

Singh JA, et al. Arthritis Care Res (Hoboken). 2012;64:625-639; Smolen JS, et al. Ann Rheum Dis. 2010;69:631-637; Smolen JS, et al. Ann Rheum Dis. 2017;76:960-977.

• Frequent disease activity

assessments (1-3 months for active disease) recommended to assess treatment response

• If no improvement by 3 months or

target has not been reached by 6 months, treatment adjustment is warranted

Active RA Clinical remission (eg, DAS) Clinical sustained remission LDA Sustained LDA MAIN TARGET ALTERNATIVE TARGET

• Measure disease

activity every 1-3 months

• Adapt therapy

accordingly

• Measure disease

activity ~3-6 months

• Adapt therapy if

state is lost

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Biologic Monotherapy for RA: Sarilumab vs Adalimumab

*Difference: -1.08 (95% CI: -1.36 to -0.79)

LS = least squares. Burmester GR, et al. Ann Rheum Dis. 2017;76:840-847.

• Phase 3 study examined

sarilumab vs adalimumab as monotherapy in patients with RA

• Primary endpoint was change

from baseline in DAS28-ESR at week 24

• Sarilumab demonstrated

‒ 49% greater improvement in DAS28-ESR ‒ Reductions in disease activity and signs and symptoms of RA

• 2.2
• 3.28*
• 5
• 4
• 3
• 2
• 1

12 24

LS mean change from baseline Week

Change in DAS28-ESR

Adalimumab, 40 mg q2w (n = 185) Sarilumab, 200 mg q2w (n = 184)

P <0.0001 Primary Endpoint

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JAK Inhibitors (Targeted Synthetic DMARDs) in Treatment of Moderate to Severe RA

• Tofacitinib

‒ For patients with inadequate response to MTX ‒ Do not use with biologic DMARDs or potent immunosuppressants

• Baricitinib

‒ For patients with inadequate response to ≥1 TNF inhibitor(s) ‒ Do not use with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants (eg, azathioprine, cyclosporine)

• Upadacitinib (most recently approved DMARD for RA)

‒ For patients with inadequate response to or intolerance of MTX ‒ Do not use with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants

Xeljanz [prescribing information].Pfizer; 2019; Olumiant [prescribing information]. Lilly USA; 2019; Rinvoq [prescribing information]. AbbVie: 2019.

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ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03025308?term=filgotinib&cond=Rheumatoid+Arthritis&draw=2&rank=2. Accessed June 1, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT02308163?term=Peficitinib&cond=Rheumatoid+Arthritis&draw=2&rank=2. Accessed May 27, 2020.

Emerging Treatments in Moderate to Severe RA

Filgotinib (Phase 3)

• JAK1 selective inhibitor

Peficitinib (Phase 3)

• Pan-JAK inhibitor, moderately selective for JAK3

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Observations from the Epidemiological Investigation of RA and the Swedish Rheumatology Register Cohorts

Overall Cohort N = 994 MTX n = 626 No DMARD n = 109 TNF Inhibitors n = 301

Good Responders (%) 45 40 35 30 25 20 15 10 5

P = .05 P = .95 P = .42 P = .01 P = .07 P = .03 P = .52 P = .04

Smoking Status: Never Past Current

Smoking Blunts RA Treatment

Response in overall cohort and in subgroups receiving MTX or clinical care without a DMARD at baseline, as well as in those receiving subsequent TNF inhibitors. Saevarsdottir S, et al. Arthritis Rheum. 2011;63:26-36.

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Responsibilities of Primary Care Clinicians as Part of a Multidisciplinary Team in RA

• Symptom management
• Monitor for comorbidities and

extra-articular manifestations

• AE monitoring
• Smoking cessation counseling
• Nutrition and weight management
• Referrals as needed to

– Rheumatology – Cardiology – Pulmonary – Occupational therapy – Psychiatry

• Pregnancy counseling

Hill J, et al. Musculoskeletal Care. 2003;1:5-20; Hooker RS, et al. Health Soc Care Community. 2012;20:20-31; Solomon DH, et al. Arthritis Care Res (Hoboken). 2014;66:1108-1113.

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Don’t Neglect CVD Risk in Patients With RA

Agca R, et al. Ann Rheum Disease. 2017;76:17-28; Chodara AM, Curr Rheumatol Rep. 2017;19:16; Peters MJ, et al. Ann Rheum Dis. 2010;69:325-331.

• RA is an independent risk factor for CVD
• Patients with RA have an increased risk of CVD and a 50% to 70% greater risk
• f heart disease compared to the general population
• EULAR recommendations for CVD risk management in RA

‒ Assess CVD risk regularly ‒ Include total cholesterol and high-density lipoprotein cholesterol as part of risk assessment ‒ Measure lipids when disease activity is stable or in remission ‒ Consider screening for asymptomatic atherosclerotic plaques with carotid ultrasound

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Extra-Articular Manifestations and Common Comorbidities in RA

• Extra-articular manifestations include:

‒ CVD ‒ Pulmonary disease ‒ Ocular inflammation ‒ Nodules ‒ Neuropathies ‒ Myopathies

Atzeni F, et al. Autoimmun Rev. 2013;12:575-579; Avina-Zubieta JA, et al. Arthritis Rheum. 2008;59:1690-1697; Cutolo M, et al. Semin Arthritis

• Rheum. 2014;43:479-488; Furst DE, et al. Ann Rheum Dis. 2012;71(Suppl 2):i2-i45; Makol A, et al. Rheum Dis Clin North Am. 2012;38:771-793;

Primdahl J, et al. Ann Rheum Dis. 2013;72:1771-1776; Singh JA, et al. Arthritis Care Res (Hoboken). 2016;68:1-25; Young A, Koduri G. Best Pract Res Clin Rheumatol. 2007;21:907-927; Klodzinski T, et al. Reumatologia. 2018;56:288-233.

• Comorbidities include:

‒ Cardiovascular, lung, and kidney diseases ‒ GI disorders ‒ Infections ‒ Malignancies ‒ Osteoporosis ‒ Depression

• RA is a systemic disease with sequelae beyond joint damage

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• Older male patient with moderately

severe interstitial lung disease (ILD), primarily involving the mid and lower lung fields

• Most common form of ILD in RA is

interstitial pneumonitis

Rheumatoid Lung in an Elderly Man

Image courtesy of Lester Miller, MD.

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• Scleritis in an older woman with

long-standing RA

• Inflammation in the sclera becomes

thinner and translucent

• Result is the sclera having a bluish

hue from the underlying choroid layer of the eye

Ocular Scleritis in RA

Image courtesy of Lester Miller, MD.

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Vaccine Considerations in RA

Live vaccines to be avoided when using biologics

• Herpes zoster (shingles) [Zostavax only]*
• Live attenuated viral/intranasal spray for influenza
• Adenovirus
• Cholera
• Measles, mumps, rubella
• Measles, mumps, rubella, varicella
• Rotavirus
• Typhoid (live attenuated bacterial oral)
• Varicella
• Vaccinia (smallpox)
• Yellow fever

Important points to remember

• Inactivated influenza and pneumococcal

vaccines are strongly recommended and are safe, but therapeutic response may be reduced

• If a live vaccine is indicated, administer 4 weeks

before starting therapy

• Routine immunizations should be up to date

before travel

*Shingrix is an inactivated recombinant, adjuvanted (non-live) vaccine for herpes zoster. Centers for Disease Control and Prevention. www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/appdx-full-b.pdf. Accessed May 27, 2020; Wine-Lee L, et al. J Am Acad Dermatol. 2013;69:1003-1013.

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Coordinating Multidisciplinary Treatment Teams

Taal E, et al. Clin Rheumatol. 2006;25:189-197.

• Develop relationships with at least

1 to 2 rheumatology specialists to facilitate timely referrals

• Multidisciplinary teams do not have

to practice together in the same building or setting

RA PATIENT

Rheumatology Specialty Care

Primary Care MD, PA, NP Cardiology Pulmonology Physical Therapy Psychology Orthopedics Social Work

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ACR: RA Treatment Recommendations in the Context of COVID-19

AZA = azathioprine; CSA = cyclosporine; CQ = chloroquine; HCQ = hydroxychloroquine; LEF = leflunomide; MMF = mycophenolate mofetil; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; SSZ = sulfasalazine. Mikuls TR, et al. Arthritis Rheum. 2020:[Epub ahead of print].

• Patients exposed to SARS-CoV-2

‒ Continue HCQ/CQ, SSZ, NSAIDs ‒ Temporarily halt immunosuppressants pending a negative test for COVID-19 or 2 weeks of symptom-free observation:

• Tacrolimus, CSA, MMF, AZA
• Non-IL-6 biologics
• JAK inhibitors

‒ IL-6 inhibitors may be continued in select circumstances, as part of a shared decision-making process

• Patients with documented or presumptive

COVID-19 ‒ Regardless of COVID-19 severity, HCQ/CQ may be continued, but SSZ, MTX, LEF, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped or held ‒ In patients with severe respiratory symptoms, NSAIDs should be stopped ‒ IL-6 inhibitors may be continued in select circumstances, as part of a shared decision-making process

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IL-6 Agents in Clinical Trials for COVID-19

ClinicalTrials.gov. clinicaltrials.gov/ct2/results?cond=COVID&term=sarilumab&cntry=&state=&city=&dist=. Accessed May 27, 2020; ClinicalTrials.gov. clinicaltrials.gov/ct2/results?cond=COVID&term=Tocilizumab&cntry=&state=&city=&dist=. Accessed May 27, 2020.

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Case Conclusion

• Tara is given a PCR test for COVID-19; result was negative, and she did

not develop symptoms

• She achieves clinical remission 3 months after switching to sarilumab

monotherapy

• She is finally able to quit smoking
• Loses 15 lb by increasing exercise and following a low-fat diet with

anti-inflammatory benefits

• Multidisciplinary team will continue to monitor her RA disease activity and

quality of life, assess for any radiologic changes, and follow for AEs, extra-articular manifestations, and comorbidities

PCR = polymerase chain reaction.

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PCE Action Plan

✓ Discuss with patients that the goal is to achieve clinical remission ✓ Adjust treatment if the therapeutic target has not been achieved in 6 months ✓ Consider RA as an independent risk factor for CVD ✓ Identify members of your expanded care team and promote collaborative care PCE Promotes Practice Change

2020 Symposia Series 2