November 2001 • POST-ASSEMBLY EDITION
New agents, therapies offer arthritis patients new hope
For decades, patients with "regular, garden-variety arthritis" believed their family physician could do nothing for them, and about 40 percent of them still believe their aches and pains can't be treated.
But today's increased understanding of this disease, paired with the introduction of new agents and therapies at a rapid rate, can provide many patients with renewed hope, said FP Cheryl Lambing, M.D., of Ventura, Calif.
Lambing presented "New Treatment Options for Arthritis" Oct. 3 as a Scientific Assembly mini-course. She is assistant clinical professor in the University of California at Los Angeles Department of Family Medicine, a faculty member of the family practice residency at Ventura County Medical Center and co-director of the rheumatology teaching clinic there.
Lambing believes there's never been a more important or exciting time to learn about arthritis. "As family physicians," she said, "we all need to be knowledgeable about the condition and the treatments -- including new and emerging agents."
Some of the more significant treatment advances address the needs of patients suffering from rheumatoid arthritis, the most prevalent type of arthritis, which affects more than 2 million people nationwide, Lambing said.
The old approach to treating RA would begin with extensive lab tests and X-rays. After the diagnosis, the physician would slowly introduce different agents and await results, concentrating on pain management. Today, Lambing said, "We've seen a huge therapeutic shift for most of these patients."
The traditional "pyramid approach" has been reversed to provide aggressive early intervention, thus slowing the disease and managing patients' pain, she says. "Now we know you can start an agent today. And we have lots of choices. In fact, combination therapy (using new and standard medications) has become the norm."
Methotrexate has been a standard pharmacologic treatment for RA patients for 20 years, she said, because 80 percent of patients using it for five years get good results when compared with patients who used earlier remedies such as gold salts. In fact, "every other agent is compared to methotrexate, because we have 20 years of experience with it," she said.
Generally, methotrexate is well tolerated. Originally a chemotherapy drug, it slows progression of the disease with only minor toxicity concerns, improving long-term outcomes, Lambing said.
Adding new nonsteroidal anti-inflammatory drugs, such as celecoxib and rofecoxib, and disease-modifying antirheumatic drugs, such as leflunomide, etanercept and infliximab, often brings quicker relief. For example, Lambing told of how she prescribed etanercept for a walker-dependent patient, and, two weeks later, the patient walked into her office without aid. "It's the only agent in 10 years that I've seen work that quickly," she said.
However, using these agents requires increased lab testing during treatment, Lambing added, to monitor for multiple toxicities and gastrointestinal problems. In addition, pain relief may plateau in some patients. "So you have to monitor the dosage and modify combinations," she said.
Remember that no long-term trial data are available for these newer drugs, Lambing said. And because of their popularity, production is backed up, so patients may have to wait weeks for their prescription.
Another key drawback is cost. Etanercept currently costs about $12,000 per year for the average dose, and infliximab, which is given intravenously, costs $9,000 per year for six infusions.
Granted, these new aggressive treatment options require increased patient assessments and diligent monitoring by the physician, Lambing said, but that very process "is always good for the patient."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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