Acr 2012 updates and Philippine applicability

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I was asked to discuss recently the latest guidelines with the fellows. Here's my work. I also included some slides on how to apply for support via Phil Charity Sweepstakes Office.

I was asked to discuss recently the latest guidelines with the fellows. Here's my work. I also included some slides on how to apply for support via Phil Charity Sweepstakes Office.

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  • 1. DMARDs in RASIDNEY ERWIN T. MANAHAN, MDInternal Medicine - Rheumatology2012 ACR Update
  • 2. Disclosures• Training sponsorship from Pfizer• Speakers’ Bureau for Celebrex and Lyrica, Pfizer• Honoraria from Ajanta Phils (Atenurix)• Participated in clinical drug trials for Roche, Wyeth,Novartis, and Parexel
  • 3. 1996• Goals oftreatment• Evaluationtools in RA• Management2002• New drugs• Benefit ofearlytreatment2008• Definedscenarios• Indicationsfor initiatingor resumingDMARDS
  • 4. 2012• Defines “Treat to Target”• Progressing DMARDtreatment• Vaccination Schedule• Updates on TB Screening
  • 5. Defining ScenariosDURATION• EARLY - <6 months• ESTABLISHED - >6months OR satisfies 1987ACR Criteria for RADISEASE ACTIVITY• LOW• MODERATE• HIGH
  • 6. FEEARunctional Disabilityxtra-articular DiseaserosionsCPA PositivityF PositivityPoor Prognostic Factors
  • 7. Treat-to-TargetTools Remission Low Moderate HighPATIENT-DRIVEN COMPOSITE TOOLSPAS <0.25 0.26-3.70 3.71-7.99 >8.00RAPID-3 <1.0 >1.0-2.0 >2.0-4.0 >4.0PATIENT-PROVIDER COMPOSITE TOOLSCDAI <2.8 >2.8-10.0 >10.0-22.0 >22.0PATIENT, PROVIDER, LABORATORY COMPOSITE TOOLSDAS28 <2.6 >2.6-<3.2 >3.2-<5.1 >5.1SDAI <3.3 >3.3-<11.0 >11.0-<26.0 >26.0
  • 8. Medication List• Methotrexate (MTX)• Leflunomide (LEF)• Sulfasalazine (SSZ)• Hydroxychloroquine(HCQ)• Minocycline• MTX + HCQ• MTX + LEF• MTX + SSZ• SSZ + HCQ• MTX + SSZ + HCQ• Infliximab (INF)• Etanercept (ETN)• Adalimumab (ADA)• Golimumab (GOL)• Certolizumab Pegol• Abatacept (ABA)• Rituximab (RTX)• Tocilizumab (TCZ)Items in bold readily available locally
  • 9. EarlyDiseaseDMARD Monotherapy• Low Disease Activity• Moderate Disease Activitywithout Poor PrognosticFeaturesMTX + HCQ• High Disease Activitywithout Poor PrognosticFeaturesDMARD Combination• Moderate-High DiseaseActivity with PoorPrognostic FeaturesAnti-TNF + MTX• High Disease Activity withPoor Prognostic Features *
  • 10. EarlyDiseasePH StyleDisease ActivityPoor Prognostic FactorsAbsent PresentLow MTX or HCQ MTX or HCQModerate MTX or HCQ MTX + HCQHigh MTX + HCQMTX + HCQAnti-TNF + MTX
  • 11. EstablishedDiseaseDMARD Monotherapy• Low Disease Activity withoutPoor Prognostic FeaturesMTX Monotherapy ORDMARD Combination• Low Disease Activity withPoor Prognostic Features• Moderate-High DiseaseActivity regardless of PoorPrognositc Features**
  • 12. EstablishedDiseasePH StyleDisease ActivityPoor Prognostic FactorsAbsent PresentLow MTX or HCQMTXMTX + HCQModerateMTXMTX + HCQMTXMTX + HCQHighMTXMTX + HCQMTXMTX + HCQ
  • 13. ShiftingTreatmentDMARD Monotherapy• Add MTX, LEF or HCQMTX MonotherapyOR MTX Combination• Add LEF, HCQ, SSZ• Shift to a non-MTX DMARDMTX Monotherapy ORDMARD Combination• Add Anti-TNF, Abatacept orRituximabIntensified DMARDCombination ORfollowing 2nd DMARD• Add Anti-TNF(3 months)
  • 14. ShiftingTreatmentAnti-TNF• Shift to another Anti-TNF• Shift to Abatacept,Rituximab or TocilizumabNon-TNF Biologic• Shift to other Non-TNFBiologic• Shift to Anti-TNF AgentNon-Serious AE whileon Anti-TNF• Shift to Another Anti-TNFSerious AE while onAnti-TNF• Shift to Non-TNFBiologic(3-6 months)
  • 15. ShiftingTreatmentPH StyleAt 3-6 months AND stillwith moderate-highdisease activityMethotrexate HCQMethotrexate + HCQAdd Anti-TNF or RTXShift to another Anti-TNF or TCZ or RTX*similar recommendationsif patient develops AEswhile on biologic agents
  • 16. High Risk PopulationsNo Biologics Untreated Hep B or Chronic Hep B Child PughClass B or CEtanercept Hepatitis CRituximab Treated solid organ tumors or non-melanomaskin CA <5 years; treated melanoma skin CA orlymphoproliferative malignanciesAny Biologic Treated solid organ tumors or non-melanomaskin CA >5 yearsNo Anti-TNFs CHF FC III or IV or EF <50%
  • 17. Before Treatment• Pneumococcal• Influenza (IM)• Hepatitis B• HPV Vaccine• Herpes Zoster Vaccine
  • 18. During Treatment• Pneumococcal• Influenza (IM)• Hepatitis B• HPV Vaccine• Herpes Zoster Vaccine******Not recommended if giving Biologics
  • 19. All Candidatesfor BiologicsShould BeScreened for TB• Tuberculin Skin Test• Interferon GammaRelease Assays (IGRA)• Chest X-rays• Sputum AFB
  • 20. Prioritize TBLatent TB• Complete at least 1month treatment beforestarting biologicsActive TB• Completion of 6 monthstreatment before startingbiologics****“How about Contacts?”(Refer to 2006 Guidelines)****BTS – allowable after 2 months
  • 21. Reviewed 2012 ACR Updates• Treat to Target• What Drugs to Start• How to Shift Therapy• Vaccination Schedule• TB Screening
  • 22. Algorithm from 2008 ACR
  • 23. Biologics Cost ComparisonName and Strength Brand FrequencyMonthlyCosts ($)Etanercept 25 mg PFS Enbrel Twice a week 1,197Etanercept 50 mg PFS Enbrel Once a week 2,444Infliximab 100 mg/vial Remicaide Every 4-8 weeks 2,296Rituximab 500 mg/ vial Rituxan Every 24 weeks 1,324Tocilizumab 200 mg/ vial Actemra Every 4 weeks 1,797Tocilizumab 400 mg/ vial Actemra Every 4 weeks 1,825*Prices as of December 2012
  • 24. SafetyEfficacyCostsConsiderationsin PrescribingTreatment
  • 25. Philippine Charity Sweepstakes Office
  • 26. PCSO Allocation of Funds55%15%30%PrizesOperationsCharity FundsSeptember 1979, Batas Pambansa Blg.42
  • 27. Where Do the CharityFunds Go• Mandatory Contributions• Individual Medical AssistanceProgram (IMAP)• Endowment Fund Program• Beneficiaries• Upgrading of Medical Facilities• Medicine Donations• Medical Equipment Donations• Outreach Programs• Special Programs
  • 28. IMAP Objectives• General – Restore social functioning (physical recovery)through medical assistance• Specific – Provide assistance for– Hospital expenses– Diagnostic procedures– Purchase of medicine– Chemotherapy drugs (includes biologics)– Dialysis solutions– Implants, hearing aids, prosthesis/ wheel chairs
  • 29. IMAP Requirements• Personal letter of request to the Chairman (Margarita PJuico) / General Manager (Jose Ferdinand M Rojas II)• Original/ Certified true copy of updated clinicalabstract, signed by the doctor with license # & PTR• Prescription with printed name, signature and lic #• Treatment protocol with signature and licensenumber of attending physician• Official price quotation from the pharmacy• Endorsement from hospital social service for servicepatients or credit and collection for pay patients• Social Case study report from LGU/ Barangay
  • 30. IMPORTANTREMINDERS• Abstract and prescriptionshould be updated(WITHIN 1 month)• Include photocopies oflaboratory test results• Provide treatmentprotocols
  • 31. IMAP Work FlowOfficer of the Day reviewsdocuments and triagespatients (5 mins)For Medical Evaluation (10 mins)For Completion of Documents (3 mins)Complete – documents scheduling (2 mins)Complete – Schedule for interview (15 mins)Patient submits documentsPicture Taking(1 min)Social Worker(15 mins)
  • 32. Supervisor reviews andconfirms recommendations(15 mins)Encoding/ transmittal/Preparing the GL (17 mins)Division Chief reviews andaffixes initials on the GL(15 mins)Department Manager(Approves <P50,000)Asst General Manager(Approves <P100,000)General Manager(Approves <P1,000,000)
  • 33. Releasing Section• Receives and data bankapproved IMAP cases• Releases approvedguarantee letters topatients or his/ herrelatives