Year: 2018

The following is a press release from the ACR dated today.

The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) have released a joint treatment guideline for psoriatic arthritis (PsA) that provides evidence-based pharmacologic and non-pharmacologic recommendations on caring for treatment-naïve patients with active PsA and patients who continue to have active PsA despite treatment. It also includes recommendations for vaccinations, psoriatic spondylitis, predominant enthesitis, and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections.

PsA is a chronic inflammatory musculoskeletal disease most commonly found in patients with psoriasis, a skin disease that causes red, scaly patches to appear on the skin. According to the NPF, more than 8 million Americans suffer from psoriasis, and it is estimated that 30 percent of them may develop PsA.

Some key recommendations from the guideline include:

• A conditional recommendation to use treat-to-target approach for all patients with active PsA;
• A conditional recommendation to use tumor necrosis factor inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA; and
• A strong recommendation for smoking avoidance/cessation.

“Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” said Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama at Birmingham who served as principal investigator for the guideline project. “The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation.”

The use of TNFi biologics as a first-line therapy was one of many recommendations included to help providers and patients decide between the various pharmacologic options currently available. While current GRAPPA recommendations address the use of TNFi biologics in treatment-naïve patients, this is the first guideline that specifically recommends first trying them over oral small molecule (OSM) drugs.

“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first,” said Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and member of the NPF Medical Board who served as a content expert on the guideline’s core team. “This doesn’t hold true once other symptoms and comorbidities are present, so OSMs can continue to be a first-line option for patients that have contraindications to TNFi treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy. Providers should take into consideration all active disease domains, comorbidities, and the patient’s functional status when choosing the optimal therapy for an individual at a given point in time.”

Tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs.

The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics; the benefits of smoking cessation; and the well-established link of smoking with mortality, cancers and heart and lung diseases in the general population.

The PsA guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. Due to limited data in some areas, the quality of evidence was often graded low or very low. This led to nearly all recommendations being conditional. A voting panel of rheumatologists, dermatologists, health professionals, and patients achieved consensus on the direction and the strength of the recommendations.

“Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions,” said Singh. “This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations.”

The complete guideline is available online on both the ACR website and NPF website.

The following is a press release issued by the American College of Rheumatology today.

The American College of Rheumatology (ACR) today released the Rheumatic Disease Report Card: Raising the Grade on Rheumatology Care in America, a first-of-its-kind report that evaluates just how difficult it can be to live well with a rheumatic disease in the United States.

The Rheumatic Disease Report Card provides actionable information to healthcare consumers and policymakers in all 50 states and the District of Columbia by answering the question, “How easy is it to live with a rheumatic disease in my state?” The report assigns states letter grades according to their progress in providing adequate access to rheumatology care, ensuring rheumatic disease care is affordable, and encouraging healthy lifestyle habits that ease the burden of rheumatic disease.

The average state grade was a “C,” with Maryland earning the highest grade and Oklahoma and Alabama earning the lowest grades in the report.

“This report comes at a critical time, as countless Americans living with chronic rheumatic diseases are finding it increasingly difficult to afford their prescription medications and even have access to specialized rheumatologic care,” said David Daikh, MD, PhD, President of the ACR. “This report card is an opportunity for Americans to advocate for themselves and their loved ones by raising awareness and encouraging policymakers to enact policies that improve rheumatic disease care access and affordability.”

The report findings indicate that all states have room to improve the access, affordability, and lifestyle factors associated with an individual’s ability to live well with a rheumatic disease.

A severe rheumatology workforce shortage, lack of insurance coverage and delays caused by restrictive insurer practices make it difficult for patients in many states to access rheumatic disease care. Even in states where patients can find a rheumatologist, their prescribed treatment costs are often exorbitantly expensive, as few states have taken measures to curb secretive pricing practices employed by Pharmacy Benefit Managers (PBMs) or put limits on insurers’ use of specialty tiers that implement high cost-sharing models. Furthermore, the report shows that policymakers at all levels of government can do more to make funds available for evidence-based rheumatology intervention programs like those funded by the CDC, and to support access to these programs in rural and underserved communities.

Of the 50 states and one federal district featured in the report, several states stood out as examples that others should look to as models for improving the lives of Americans with rheumatic diseases:

• Maryland was the only state to receive an overall “A” grade due to its success in having a high concentration of rheumatologists, a low uninsured rate, laws in place to keep rheumatology care affordable, and several CDC-funded arthritis intervention programs operating in the state, including those offered by the YMCA and the National Recreation and Parks Association (NRPA).
• Arkansas scored well in the affordability category due to state lawmakers’ recent efforts to address PBM transparency by enacting legislation that should serve as a model for future action in other states looking to address this issue.
• Arizona received distinction for its efforts to educate primary care physicians in remote areas about rheumatic diseases so these frontline healthcare workers can better monitor and treat minor cases locally while referring more severe cases to a practicing rheumatologist. Arizona has one of the lowest concentrations of rheumatologists in the country, with only one practicing rheumatologist for every 139,000 people. Meanwhile, in Massachusetts and Maryland, there is one rheumatologist for approximately every 20,000 people – a ratio nearly seven times higher.

Rheumatic diseases are painful autoimmune and inflammatory diseases that affect a person’s joints, muscles, bones, and organs. There are more than 100 types of rheumatic diseases, including the more commonly known diseases of osteoarthritis, rheumatoid arthritis, lupus and gout.

One in four Americans are diagnosed with a rheumatic disease, and a recent academic study suggested that the number of Americans living with rheumatic disease may be as high as 91 million when taking into account reported symptoms of undiagnosed individuals. The prevalence and cost of rheumatic diseases represent a growing public health crisis. As the nation’s leading cause of disability, rheumatic diseases generate more than $140 billion in medical costs each year in the United States – surpassing the annual medical costs of cancer care.

“Rheumatic diseases can be debilitating—but they don’t have to be if a diagnosis is made without delay and appropriate treatment is started,” said Dr. Daikh. “We hope this report will help people understand that they have the power to turn the tide on this public health crisis by taking steps to raise their state’s grade on rheumatic disease care.”

The Rheumatic Disease Report Card is a project from the American College of Rheumatology (ACR) and its Simple Tasks™ public awareness campaign. Its development was guided by a national task force comprised of leading rheumatology researchers, clinicians and policy experts.

To view the Rheumatic Disease Report Card, please visit SimpleTasks.org/ReportCard.