Imprecise Rheumatology Prescribing

I had a conversation with a couple of new pharmaceutical brand managers. They look after a biologic DMARD and were asking the usual question of how we rheumatologists decide on which biologic we commence a patient on.

I’ve written about medication choice for autoimmune inflammatory arthritis before - With so many biologics for Rheumatoid, how do you choose?

But, the bottom line is we’re imprecise when it comes to a decision like this.

This also applies to the traditional DMARDs we use in rheumatology. In rheumatoid arthritis for example, Methotrexate is first line, meaning it’s what we all typically use first up. It’s a good drug but it obviously does not work for all. 

I think rheumatologists all try to synthesise what randomised trial data we have, understanding that these might not necessarily apply to the real world patients sitting in front of us with their unique characteristics, fears and goals. The trial setting is different, controlled, with very selected patients, who are monitored and engaged very regularly.

We typically prescribe as follows:

1. Choose a medication that we have experience of and are comfortable with, with some decent evidence behind it, as long as there are not any clear contraindications in the target patient
2. Give it a go and monitor
3. If we are not winning, add another drug or swap to another drug
4. Repeat steps 1 to 3  

Trial and error plays a part, and while any guesswork is educated, there is this imprecision to accept.

Wouldn’t it be nice if rheumatologists could be more precise with how we determine the medication use?

Wouldn’t it be nice to use the right drug in the right patient at the right time?