In this month’s column, the panelists take a closer look at management considerations in patients with juvenile arthritis and those with osteoporosis and RA. They also discuss how clinicians should approach the reluctance of patients with RA to switch to newer biologic agents and their benefit-to-risk ratios.

Q: How do you approach an active RA patient who refuses to receive more aggressive therapy?

(Photo courtesy of Babak Baravarian, DPM) Here one can see forefoot deformity in a 27-year-old woman who presented with extreme pain and a 12-year history of rheumatoid arthritis.

A: Alan Kivitz, MD says he often sees a “mismatch” between the residual activity of the patient’s RA and a reluctance to not modify his or her treatment. While he believes the introduction of biologics has established a higher bar of what clinicians can accomplish to help control RA, Dr. Kivitz says there are some patients who feel like they have made progress with current regimens and are disinclined to make a change.

“Many RA patients have had the disease for many years, have been taking methotrexate for many years and — in comparison to their initial presentation — feel well,” explains Dr. Kivitz. “I look at their swollen metacarpophalangeal (MCP) joints and say ‘I can make your condition even better.’”

Dr. Kivitz says some patients do take the leap of faith and notes that most of them are thankful they did. In regard to the naysayers, Dr. Kivitz says he will spend time at each visit talking about the potential benefits of adding a biologic but they simply smile and have no intention of changing their medication regimen.

Nathan Wei, MD, has seen this in his practice as well. Regardless of what trial data may show, Dr. Wei notes many patients are still unwilling to pursue newer therapies such as biologics if they “feel well enough” with current treatment regimens and/or they cannot or do not want to spend the money for the medication. He adds this is particularly the case if patients have concerns about the potential side effects of a new medication.

Drs. Kivitz and Wei emphasize the balance of respecting patients’ wishes and continuing to educate them on the possible benefits of biologic therapies.

“Ultimately, all we can do is educate our patients and attempt to guide them to the decision that we believe is in their best interest,” adds Dr. Kivitz. “However, the patient has to be a willing participant for the next step in therapy.”

Q: What are the differences between treating adults and children with RA?
A: “Although the medicines are the same, every aspect of treating children is different,” says Tom Lehman, MD.
Not only are the diseases different, Dr. Lehman says there is a major movement to drop the term ‘rheumatoid” from juvenile rheumatoid arthritis (JRA) and refer to it as juvenile arthritis (JA) or juvenile idiopathic arthritis (JIA).

He points out that oligoarticular arthritis and systemic onset disease represent completely different diseases in children. When treating children with these diseases, Dr. Lehman says one must routinely screen for slient eye disease whereas adults with RA rarely have that problem. Dr. Lehman says different types of JA have different clinical characteristics and different outcomes.

“Even among children with polyarticular disease, only a small subset are rheumatoid factor positive and resemble adults with RA,” states Dr. Lehman.

While children often have different types of arthritis, Dr. Lehman says the available medicines used for treatment are the same as those clinicians use to treat adults with RA. He emphasizes clinicians not only have to adjust dosing given the potential of certain side effects in children but there are patient compliance factors to consider as well.

Dr. Lehman suggests that one may need to work out special arrangements in which children are able to take the medicine in liquid form or for pills to be crushed. The taste of the medicine is also more of a factor for children, according to Dr. Lehman. He states that there is often more of a frustration among children about the need to take the medicine and undergo blood testing.

Parents often worry about the potential side effects of these medications in their children. Accordingly, Dr. Lehman says clinicians need to educate and reassure the parents of the patient that giving the medicine is the right thing to do. He adds parents may need help in dealing with schools, neighbors and the child’s friends.

“The physician caring for children with arthritis must always remember that we are giving family centered care with many complicated aspects, which will impact on our success or failure,” explains Dr. Lehman.

Q: What pearls can you share when dealing with osteoporosis in an RA patient?
A: It is imperative for clinicians to start these patients on anti-tumor necrosis factor (TNF) therapy early, according to Norman Koval, MD.

Dr. Koval says medications such as infliximab (Remicade, Centocor), adalimumab (Humira, Abbott) and etanercept (Enbrel, Wyeth) reduce the activity of RANK/RANKL mediated osteoclastogenesis, a process accelerated by pro-osteoclastic signaling pathways in TNF-alpha driven diseases. He notes these medications should reduce bone loss in patients with RA.

In conjunction with these agents, Dr. Koval says one should consider using a bisphosphonate medication.

He encourages clinicians to assess Vitamin D levels in these patients. If they are abnormally low, Dr. Koval suggests using Vitamin D supplementation in the form of 50,000 units orally per week until patients have reached a normal level of 32 to 100 units of Vitamin D.

Dr. Wei says vitamin D deficiency in these patients is “extremely common,” especially in the winter.

In fact, he says 80 percent of the postemenopausal women his clinic saw last winter were vitamin D deficient. Dr. Wei recommends 50,000 IU one to two times a week for four weeks and repeating the regimen until proper levels are reached.

Dr. Kivitz is Head of the Altoona Arthritis and Osteoporosis Research Center in Altoona, Pa.
Dr. Lehman is Chief of the Division of Pediatric Rheumatology at New York Hospital, Cornell University School of Medicine in New York City.
Dr. Koval is a staff rheumatologist at Arthritis and Rheumatism Associates in Wheaton, Md.
Dr. Wei is the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md.