How do you approach selecting biologic therapy vs non-biologic DMARD (such as methotrexate) as initial therapy in patients with new RA diagnosis with significant erosive disease?

In my clinical experience, not everyone is the best candidate for methotrexate. Businessmen who feel alcohol consumption is part of their ability to finish business deals are uncomfortable taking methotrexate and I am uncomfortable prescribing for them. Men and women who are hoping to bear children sooner than later are uncomfortable starting methotrexate and I am concerned about prescribing methotrexate for them. Patients with renal insufficiency can suffer more toxicity from methotrexate and I...

I strongly endorse the use of methotrexate (MTX) as initial therapy in patients with a new RA diagnosis who have a significant erosive disease. Clearly, this subset of patients is likely to require a combination of therapies including concomitant MTX and a biological drug. Considerable evidence has demonstrated that combination therapy provides a therapeutic synergy and is generally the preferred therapy for people with more aggressive forms of RA. Starting MTX and escalating to maximum doses ov...

For practical purposes, would use MTx and at the same time apply for biologic prior authorization, this way I don’t lose time, however always start with MTX. It might suffice on its own, especially in sero-pos disease because is more sensitive to therapy.

I have more than several patients that have stable or healed erosions only taking MTX for years validated by repeat x-ray/MRI. Those with quite an inflammatory disease are started on MTX 15 mg weekly and in 6 weeks if still an active disease, I take them up to 25 mg weekly. If not significantly better at 3 months, I start the conversation for biologic therapy. I counsel young women about the abortifacient and potential fetal effects of MTX, and the need for adequate birth control and to stop MTX...

Biologics Overuse and Healthcare Costs

The overuse of biologics, costly lifelong therapies, is a prevalent issue. Discontinuing biologic therapy proves challenging due to patients transitioning between healthcare systems and rheumatologists, resulting in limited knowledge of initial presentations. It is crucial to initiate such treatments only when genuinely indicated, as the healthcare system bears significant financial burdens. Those in academia may remain unaware of the true societal costs, c...