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.

1. DMARDs in RA
SIDNEY ERWIN T. MANAHAN, MD
Internal Medicine - Rheumatology
2012 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 of
treatment
• Evaluation
tools in RA
• Management
2002
• New drugs
• Benefit of
early
treatment
2008
• Defined
scenarios
• Indications
for initiating
or resuming
DMARDS

4. 2012
• Defines “Treat to Target”
• Progressing DMARD
treatment
• Vaccination Schedule
• Updates on TB Screening

5. Defining Scenarios
DURATION
• EARLY - <6 months
• ESTABLISHED - >6
months OR satisfies 1987
ACR Criteria for RA
DISEASE ACTIVITY
• LOW
• MODERATE
• HIGH

6. F
E
E
A
R
unctional Disability
xtra-articular Disease
rosions
CPA Positivity
F Positivity
Poor Prognostic Factors

7. Treat-
to-Target
Tools Remission Low Moderate High
PATIENT-DRIVEN COMPOSITE TOOLS
PAS <0.25 0.26-3.70 3.71-7.99 >8.00
RAPID-3 <1.0 >1.0-2.0 >2.0-4.0 >4.0
PATIENT-PROVIDER COMPOSITE TOOLS
CDAI <2.8 >2.8-10.0 >10.0-22.0 >22.0
PATIENT, PROVIDER, LABORATORY COMPOSITE TOOLS
DAS28 <2.6 >2.6-<3.2 >3.2-<5.1 >5.1
SDAI <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. Early
Disease
DMARD Monotherapy
• Low Disease Activity
• Moderate Disease Activity
without Poor Prognostic
Features
MTX + HCQ
• High Disease Activity
without Poor Prognostic
Features
DMARD Combination
• Moderate-High Disease
Activity with Poor
Prognostic Features
Anti-TNF + MTX
• High Disease Activity with
Poor Prognostic Features *

10. Early
Disease
PH Style
Disease Activity
Poor Prognostic Factors
Absent Present
Low MTX or HCQ MTX or HCQ
Moderate MTX or HCQ MTX + HCQ
High MTX + HCQ
MTX + HCQ
Anti-TNF + MTX

11. Established
Disease
DMARD Monotherapy
• Low Disease Activity without
Poor Prognostic Features
MTX Monotherapy OR
DMARD Combination
• Low Disease Activity with
Poor Prognostic Features
• Moderate-High Disease
Activity regardless of Poor
Prognositc Features**

12. Established
Disease
PH Style
Disease Activity
Poor Prognostic Factors
Absent Present
Low MTX or HCQ
MTX
MTX + HCQ
Moderate
MTX
MTX + HCQ
MTX
MTX + HCQ
High
MTX
MTX + HCQ
MTX
MTX + HCQ

13. Shifting
Treatment
DMARD Monotherapy
• Add MTX, LEF or HCQ
MTX Monotherapy
OR MTX Combination
• Add LEF, HCQ, SSZ
• Shift to a non-MTX DMARD
MTX Monotherapy OR
DMARD Combination
• Add Anti-TNF, Abatacept or
Rituximab
Intensified DMARD
Combination OR
following 2nd DMARD
• Add Anti-TNF
(3 months)

14. Shifting
Treatment
Anti-TNF
• Shift to another Anti-TNF
• Shift to Abatacept,
Rituximab or Tocilizumab
Non-TNF Biologic
• Shift to other Non-TNF
Biologic
• Shift to Anti-TNF Agent
Non-Serious AE while
on Anti-TNF
• Shift to Another Anti-TNF
Serious AE while on
Anti-TNF
• Shift to Non-TNF
Biologic
(3-6 months)

15. Shifting
Treatment
PH Style
At 3-6 months AND still
with moderate-high
disease activity
Methotrexate HCQ
Methotrexate + HCQ
Add Anti-TNF or RTX
Shift to another Anti-TNF or TCZ or RTX
*similar recommendations
if patient develops AEs
while on biologic agents

16. High Risk Populations
No Biologics Untreated Hep B or Chronic Hep B Child Pugh
Class B or C
Etanercept Hepatitis C
Rituximab Treated solid organ tumors or non-melanoma
skin CA <5 years; treated melanoma skin CA or
lymphoproliferative malignancies
Any Biologic Treated solid organ tumors or non-melanoma
skin CA >5 years
No 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 Candidates
for Biologics
Should Be
Screened for TB
• Tuberculin Skin Test
• Interferon Gamma
Release Assays (IGRA)
• Chest X-rays
• Sputum AFB

20. Prioritize TB
Latent TB
• Complete at least 1
month treatment before
starting biologics
Active TB
• Completion of 6 months
treatment before starting
biologics****
“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 Comparison
Name and Strength Brand Frequency
Monthly
Costs ($)
Etanercept 25 mg PFS Enbrel Twice a week 1,197
Etanercept 50 mg PFS Enbrel Once a week 2,444
Infliximab 100 mg/vial Remicaide Every 4-8 weeks 2,296
Rituximab 500 mg/ vial Rituxan Every 24 weeks 1,324
Tocilizumab 200 mg/ vial Actemra Every 4 weeks 1,797
Tocilizumab 400 mg/ vial Actemra Every 4 weeks 1,825
*Prices as of December 2012

24. Safety
Efficacy
Costs
Considerations
in Prescribing
Treatment

25. Philippine Charity Sweepstakes Office

26. PCSO Allocation of Funds
55%
15%
30%
Prizes
Operations
Charity Funds
September 1979, Batas Pambansa Blg.42

27. Where Do the Charity
Funds Go
• Mandatory Contributions
• Individual Medical Assistance
Program (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 P
Juico) / General Manager (Jose Ferdinand M Rojas II)
• Original/ Certified true copy of updated clinical
abstract, signed by the doctor with license # & PTR
• Prescription with printed name, signature and lic #
• Treatment protocol with signature and license
number of attending physician
• Official price quotation from the pharmacy
• Endorsement from hospital social service for service
patients or credit and collection for pay patients
• Social Case study report from LGU/ Barangay

30. IMPORTANT
REMINDERS
• Abstract and prescription
should be updated
(WITHIN 1 month)
• Include photocopies of
laboratory test results
• Provide treatment
protocols

31. IMAP Work Flow
Officer of the Day reviews
documents and triages
patients (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 documents
Picture Taking
(1 min)
Social Worker
(15 mins)

32. Supervisor reviews and
confirms recommendations
(15 mins)
Encoding/ transmittal/
Preparing the GL (17 mins)
Division Chief reviews and
affixes 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 bank
approved IMAP cases
• Releases approved
guarantee letters to
patients or his/ her
relatives