CvS | Feb

Treatment goals for RA: Is it time to transition MOAs?

  •  16-minute listen

Rheumatologists Dr. Christina Charles-Schoeman and Dr. Manish Jain discuss their approaches to setting and pursuing treatment goals for patients with poorly controlled RA after TNFis

Podcast

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Dr. Christina Charles-Schoeman & Dr. Manish Jain • March 2025
1X

The experts

Christina Charles-Schoeman, MD, MS

Professor of Medicine
Chief of the Division of Rheumatology
UCLA Health
Los Angeles, CA

Manish Jain, MD

Attending Physician Ravenswood Rheumatology Chicago, IL

What would you do?

In the podcast, a patient case was discussed:
Hypothetical patient image, not reflective of patient discussed in podcast.

Patient A

60 years old, female
Key case details:
  • Longstanding erosive RA
  • Did not achieve LDA/remission after >3 years of TNFi + MTX treatment
  • Recent diabetes diagnosis

How would you treat Patient A?

Question 1 of 2

If you were treating Patient A, what treatment would you recommend next?(Required)

If your patients have uncontrolled RA, their disease may be progressing

Potential consequences of uncontrolled disease
Hypothetical patient image, not reflective of patient discussed in podcast.

Loss of physical function and quality of life1–3

Socioeconomic and psychological burden4–7

Comorbidity risk

(CVD,4,8,9 infection,10,11 malignancy4,12)

Review the data on disease duration and remission:

In the podcast, Dr. Charles-Schoeman discussed this study on the relationship between disease duration and the achievement of remission

Every patient deserves to
achieve disease control

Are you taking the key steps to get your patients on the path to disease control?

Monitor disease regularly

ACR guidelines recommend13:
Frequent monitoring of disease activity using validated instruments

Evaluate current treatment

ACR guidelines recommend13:
In the absence of improvement, reevaluate therapy within 3 months

If your patient is not achieving disease control, consider a change in treatment

ACR guidelines recommend13,*:
Switching to a treatment of a different class over cycling treatments of the same class

*Based on very low-certainty evidence supporting greater improvement in disease activity and drug survival among patients switching classes. The recommendation is conditional because patient and physician preferences are likely to vary based on prior experiences with specific DMARDs.

Explore the full ACR guidelines

Read more about the latest RA guidelines

Review real-world data

In the podcast, Dr. Charles-Schoeman discussed this study on real-world disease monitoring and
treatment reevaluation

Could a switch in MOAs after TNFi failure bring your patients closer to their treatment goals?

Switching is associated with an increased probability of improvement in disease control measures14–19
Results of a network meta-analysis assessing the probability that MOA switching (vs TNFi cycling) was the better strategy for achieving clinical outcomes found14:
HAQ improvement
88%
probability that MOA switch is better
than TNFi cycling after first-line TNFi failure*
DAS28 remission
64%
probability that MOA switch
is better

than TNFi cycling after first-line TNFi failure†

Improved DAS28 remission may include improvements in20:

Swollen joint count

Tender joint count

Patient’s global health (VAS)

Review the full study here, including a meta-analysis of other disease outcomes (ACR response, treatment withdrawal, etc.)

Study details: The network meta-analysis comprised RCTs and observational studies identified via a literature search in 2018. To account for the wide range of study populations and designs, the results presented are from two models to conduct the network meta-analysis: fixed-effect or Bayesian hierarchical. The authors determined the model presented for the primary results of each outcome (above) based on the deviance information criterion.

*Analysis using a randomized-effect model of six RCTs and two observational studies.
†Analysis using a Bayesian hierarchical network meta-analysis of five RCTs.

Additionally, patients who switched MOA have been observed to be:

Less likely to change treatments again15

More likely to adhere to treatment16

More data on TNFi cycling vs MOA switching is coming soon:

SUNSTAR (NCT03227419)

ABA vs TCZ in TNFi-IR patients with RA

ADDORA-switch (NCT04251741)

TNFi vs non-TNFi after ADA failure based on ADA serum concentration

SELECT-SWITCH (NCT05814627)

UPA vs ADA in TNFi-IR patients with RA

Your patients deserve the opportunity to achieve disease control

Consider when a treatment switch in RA may be the right transition for your patients

Resource

PDF icon

Learn more about when to consider a treatment switch: Downloadable infographic

Find additional details about the information reviewed here, as well as additional data to support your clinical decision-making

PDF icon

Learn more about when to consider a treatment switch: Downloadable infographic

Find additional details about the information reviewed here, as well as additional data to support you clinical decision-making

Download infographic

Explore related topics on RheumNow.com

Switching to a new MOA vs TNFi cycling

Watch additional discussions on the guidelines and hear clinical insights from Dr. Pope and Dr. Fleischmann on treatment after first TNFi failure

Switching to a new MOA vs TNF cycling

Watch additional discussions on the guidelines and hear clinical insights from Dr. Pope and Dr. Fleischmann on treatment after first TNFi failure

Comorbidity risk in RA

Hear insights from Dr. Curtis and
Dr. Giles as they review additional data on the relationship between disease activity and comorbidity risk, including CVD and infection risk

Comorbidity risk in RA

Hear insights from Dr. Curtis and Dr. Giles as they review additional data on the relationship between disease activity and comorbidity risk, including CV and infection risk

Abbreviations:
ACR, American College of Rheumatology; ABA, abatacept; ADA, adalimumab; CVD, cardiovascular disease; DAS28, Disease Activity Score 28; DMARD, disease modifying antirheumatic drug; HAQ, health assessment questionnaire; IR-inadequate responder; LDA, low disease activity; MOA, mechanism of action; MTX, methotrexate; RA, rheumatoid arthritis; RCT, randomized controlled trial; TCZ, tocilizumab; TNFi, tumor necrosis factor inhibitor; UPA, upadacitinib; VAS, visual analog scale.

References:
  1. Ajeganova S, Huizinga T. Ther Adv Musculoskelet Dis. 2017;9(10):249–262.
  2. Einarsson JT et al. J Rheumatol. 2016;43(6):1017–1023.
  3. Contreras-Yáñez I et al. BMC Musculoskelet Disord. 2017;18(1):379.
  4. McInnes IB, Schett G. N Engl J Med. 2011;365(23):2205–2219.
  5. Sokka T et al. Arthritis Res Ther. 2010;12(2):R42.
  6. Kim D et al. J Rheumatol. 2017;44(8):1112–1117.
  7. Kekow J et al. Rheumatology (Oxford). 2011;50(2):401–409.
  8. Myasoedova E et al. Ann Rheum Dis. 2016;75(3):560–565.
  9. Solomon DH et al. Arthritis Rheumatol. 2015;67(6):1449–1455.
  10. Mehta B et al. RMD Open. 2019;5(1):e000935.
  11. Listing J et al. Rheumatology (Oxford). 2013;52(1):53–61.
  12. Baecklund E et al. Arthritis Rheum. 2006;54(3):692–701.
  13. Fraenkel L et al. Arthritis Care Res (Hoboken). 2021;73(7):924–939.
  14. Migliore A et al. Ther Adv Musculoskelet Dis. 2021;13:1759720X211002682.
  15. Wei W et al. Adv Ther. 2017;34(8):1936–1952.
  16. Caporali R et al. Adv Ther. 2024;41(9):3706–3721.
  17. Perkins K et al. J Manag Care Spec Pharm. 2023;29(10-a Suppl.):M11.
  18. Bogas P et al. Ther Adv Musculoskelet Dis. 2021;13:1759720X211060910.
  19. Gottenberg JE et al. JAMA. 2016;316(11):1172–1180.
  20. Prevoo ML et al. Arthritis Rheum. 1995;38(1):44–48.

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