10 Answers to “When Do I Start a Biologic Treatment for Rheumatoid Arthritis?”

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Patients ask: How do I know it’s time to start a biologic?

This question was recently posted on our Facebook page and it’s one most patients ask at some point. Initiating Biologic therapy is a decision that is obviously made together with your doctor. Here are some factors in this important decision.


One important source of information: The 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis.

Scroll down 8 pages to Figure 1 for a flow chart about treatment decisions in early disease, “2012 American College of Rheumatology recommendations update for the treatment of early rheumatoid arthritis (RA), defined as a disease duration <6 months.” And Figure 2., on the following page, illustrates recommendations for more established disease: “2012 American College of Rheumatology (ACR) recommendations update for the treatment of established rheumatoid arthritis (RA).”

The purpose of the recommendations appears to be improved care. Remember last February the ACR reported that “Substantial numbers of RA patients with active disease did not receive care consistent with the current ACR treatment recommendations,” Arthritis and Rheumatism.

10 keys facts to know about when to start Biologic treatments

1) Biologics have been used since 1998: So Biologic treatments for Rheumatoid Disease are not as mysterious as they once were, but still a huge step for many patients.

2) After methotrexate “fails”: Methotrexate is usually used first and non-responders may decide to add a Biologic therapy.

3) With moderate to high disease activity: Higher disease activity indicates to a rheumatologist that there is greater risk of damage occurring and a Biologic may be indicated.

4) After 3 months: A key guideline is to reassess after three months of treatment to decide whether to increase doses or escalate to a Biologic.

5) When DMARDs are not tolerated: Disease modifying antirheumatic drugs are tried first, but if methotrexate or other DMARDs are not tolerated, Biologics are an option.

6) With signs for poor prognosis: Poor prognosis includes one or more of these: functional limitation, extra-articular disease (presence of rheumatoid nodules, Rheumatoid vasculitis, Felty’s syndrome), positive rheumatoid factor or anti–cyclic citrullinated peptide antibodies, or bony erosions shown on x-ray.

7) After multiple DMARD failures: Even with lower disease activity, Biologics may be used after multiple or combination DMARDs fail.

8 ) After a Tuberculosis screening: Either a skin test or an x-ray will be required. Note: a study presented at the recent ACR meeting indicated a considerable percentage of patients are not tested; Tuberculosis testing is an important safety precaution.

9) Never with another Biologic: Biologics are currently used in combination only in experimental settings.

10) When you are informed: When you and your doctor have discussed risks and benefits of a Biologic in your particular circumstances.

If you started a Biologic treatment, how did you decide?

Key reading on these topics

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Kelly Young. All rights reserved.

This entry was posted on Tuesday, December 11th, 2012 at 5:55 am and is filed under Treating RA. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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