Conversations in Rheumatoid Arthritis (RA) Therapy: Choosing Between Subcutaneous Injections and Infusion Therapy © Thinkstock by Getty Images
As we consider how to approach our decision-making in selecting a biologic disease-modifying anti-rheumatic drug, specifically the tumor necrosis factor antagonists (anti-TNFs), we are confronted with many questions: • Which modality will work best for each patient, subcutaneous self-injection or infusion? • What are our patients’ fears and concerns, including efficacy and safety issues, for each therapy? • How do their individual insurance benefits and financial obligations influence their choices? • How can we as clinicians better answer these questions and outline the pros and cons of each modality and the impact on their decision? It is crucial to encourage shared decision-making between patient and physician. We need to initiate the conversation with our patients to educate them so that they may be able to make informed decisions, and we need to encourage them to feel comfortable enough to express their feelings and ask questions. Additionally, we need to have further discussions when we consider switching agents, whether it is due to incomplete response, adverse events, insurance issues, or patient preference.
Sincerely,
Ellen M. Field, MD, FACR FACULTY REVIEWER Ellen M. Field, MD, FACR Rheumatologist Lehigh Valley, Pennsylvania
Dr. Field is a paid consultant for Janssen Biotech, Inc.
W
hen it comes time for your patient with rheumatoid arthritis (RA) to receive treatment with a biologic diseasemodifying antirheumatic drug (DMARD), and specifically 1 of the 6 tumor necrosis factor antagonists (anti-TNFs), do you have that all-important conversation to determine which modality—infusion therapy (IV) or subcutaneous self-injection (SQ)—is right for them? A recent survey of 243 RA patients and 103 prescribers found discordance between physicians’ assumptions and patients’ actual preferences regarding IV and SQ delivery.1 Although surveyed rheumatologists thought that patients would prefer SQ injections over IV therapy, patients were equally distributed in their preferences, with 16% choosing SQ only and 14% opting for IV therapy only.1 More surprising, 53% of patients were open to trying either therapy, compared with 41% of physicians who made that assumption (Figure 1).1
When these same patients and physicians were asked to allocate 100 points across various biologic therapeutic options and administration schedules according to patient preference, the mean scores demonstrated that patients prefer SQ injections every 4 weeks or monthly ( Table 1). Patients’ second-most preferred option was IV therapy for 30 minutes every 8 weeks. The respondents cited frequency of administration, time to complete an infusion, and site of care as factors in deciding between SQ and IV therapy.1 DISCUSS FIRST, THEN PRESCRIBE Why all the attention to patients’ choosing between SQ and IV therapy? It matters, say the American College of Rheumatologists (ACR) and the European League Against Rheumatism (EULAR), because empowered patients tend to have better outcomes and greater satisfaction.2,3 Preferences may vary according to patients’ age, sex, employment
FIGURE 1. Physicians’ assumptions of patients’ openness to biologic therapeutic choices1
60% 53% Proportion of Patients (%)
Dear Colleague:
50% 41%
40%
34%
30% 20%
14% 13%
16%
16%
12%
10% 0% IV Only
SQ Only
% Patient Reported n=243 rheumatoid arthritis patients
Both
Neither
Prescriber Reported Mean % Patients n=103 rheumatologists
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