Medication Therapy Choice, Management Strategies in Inflammatory Diseases

Specialty pharmacists a crucial role in optimizing the treatment of patients with inflammatory diseases, such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS), according to a session held at the National Association of Specialty Pharmacy 2019 Annual Meeting and Expo.

For patients with these diseases, symptoms can be debilitating and interrupt their daily lives. Furthermore, these conditions can progress to irreversible joint damage if left unmanaged. Once a diagnosis of an inflammatory disease is established, pharmacists can help patients and their care teams determine an appropriate therapeutic strategy.

In the session, Nancy Crowell, RPh, vice president of operations at Senderra Rx, provided an update on the different management strategies and treatment options available for these 3 inflammatory conditions. Disease management often includes a variety of options, which depend on individual patient needs, such as nonpharmacological and preventive therapies, pharmacologic therapy, and a treat-to-target strategy, according to Crowell.

A pretreatment evaluation is key to choosing the right medication therapy, and a pharmacist should perform an assessment for every patient, Crowell said. “The pharmacist assessment is important in confirming that a prescribed therapy is indeed appropriate, and if it’s not, then we need to have alternative choices in place that we can talk to the physician about,” she said.

Considerations when choosing a medication therapy include the patient’s level of disease activity, comorbid conditions, payer mandates, previous therapies, and patient preferences. Of the pharmacologic therapies available, there are symptomatic treatments, conventional biological diseasemodifying antirheumatic drugs (DMARDs), biological DMARDs, and nonbiological DMARDs, interleukin inhibitors, and T-cell costimulation modulators.

SYMPTOMATIC TREATMENTS

Both nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be used for symptom management in all 3 disease states. Crowell noted that patients with AS often have better outcomes with NSAIDs than patients with RA. Other options include glucocorticoids and Acthar Gel (repository corticotrophin injection). With glucocorticoids, Crowell explained that oral therapy should generally be avoided in PsA, as it may exacerbate psoriasis. Acthar Gel should be used as more of a “last-ditch type of effort,” due to difficulty getting prior authorizations for the medicine, Crowell said.

CONVENTIONAL DMARDS

Conventional DMARDs for all 3 diseases include leflunomide, methotrexate, and sulfasalazine; however, there are limited data for the efficacy of leflunomide in AS. Hydroxychloroquine can be used off label for patients with RA, according to Crowell.

BIOLOGICAL DMARDS

These are the tumor necrosis factor blockers that can be used for all 3 conditions:

• etanercept (subcutaneous)
• golimumab (subcutaneous and intravenous)
• infliximab and biosimilars (intravenous)
• adalimumab (subcutaneous)
• certolizumab pegol (subcutaneous)

INTERLEUKIN INHIBITORS

In RA, options include the interleukin (IL)-1 receptor antagonist anakinra (subcutaneous) and the IL-6 receptor antagonist tocilizumab (subcutaneous and intravenous). The IL-17A antagonist ixekizumab (subcutaneous) and the IL-12 and 23 antagonist ustekinumab (subcutaneous) can be used in patients with PsA. Patients with AS can be treated with ixekizumab.

T-CELL COSTIMULATION MODULATOR

Abatacept (intravenous and subcutaneous) can be used in RA and PsA; however, dosing for the intravenous formulation depends on patient weight. Crowell emphasized the importance of checking the dosing for any medications that are dose dependent.

NONBIOLOGICAL DMARDS

Janus kinase inhibitors baricitinib (oral), tofacitinib (oral), and upadacitinib (oral), which was just approved in 2019, are nonbiological DMARD options for RA. Tofacitinib (oral) can also be used in patients with PsA.

Additionally, PDE4 inhibitor apremilast (oral) is a treatment option for patients with RA or PsA. Crowell noted that apremilast is associated with some gastrointestinal (GI) intolerance, so it’s imperative that pharmacists communicate that to patients.

“It’s important to talk to the patient about the GI problems that can go on with this, because if you don’t mention it to them, they’re more than likely to stop the drug,” she explained. “That’s the kind of intervention we need.”

Advising on the potential time frame of adverse event occurrence and recommending OTC medications for relief can help improve adherence among patients, Crowell said.

She added that pharmacological treatment is an important part of a comprehensive plan to prevent progressive and destructive joint disease in these patients. Knowledge and expertise on the available treatment options are required to help guide medication choices. Once the patient is established on a therapy, it’s important to continue ongoing management to ensure that patients are receiving the best levels of care, Crowell concluded.