How Do You Know When It's Time to Change Your RA Treatment?
My rheumatologist always states that her goal is for me to not pay much attention to RA throughout the day. This sounds like everyday language for the ultimate target for RA treatment that is called clinical remission.1 This is defined as one or less than on tender joint, one or less than one swollen joint, low inflammation blood tests, and a strong patient self-assessment.
If the RA is causing issues to which I must attend during the day, then my rheumatologist believes that the medications I’m taking aren’t working well. This approach also aligns with the notion of treat to target where treatment combinations are adjusted and changed until the patient gets as close to remission as possible.
Knowing when to change your treatment with RA
Personally, I’ve been through many RA treatments including multiple NSAIDS, disease modifiers (DMARDS), and biologicals. In fact, I’m currently on my 7th biological - Rituxan infusions. But after being through so many RA treatments over the past five years, I’m very hesitant to switch medications because I’m getting to the point where choices are limited. Below are some factors that I find helpful when considering making a change.
If a doctor is using the treat-to-target model1, then their goal should be to get the patient as close to remission as possible. This goal may necessitate changing medications periodically until disease activity is as low as possible. After my many starts and stops with RA medications, I don’t tend raise the issue of switching medicines and instead rely on my rheumatologist to broach the subject. Call me gun shy – I just want to make sure that we give a treatment a fair shot before moving on. But there may be times when the patient needs speak up.
My rheumatologist always asks me how I’m feeling in terms of joint pain, swelling, fatigue. She understands that I know my body better than anyone else and takes that into account. She usually asks me, “Do you think the medicine combination is working – if not, I’m fleshing out a super Plan B.” Sometimes rheumatologists will use validated surveys of disease activity like the DAS-283 that is designed to gauge the number of tender and swollen joints plus measures of inflammation from blood tests. There’s a nifty online DAS-28 calculator that patients and doctors can use.
Increase in inflammatory and other blood markers
A sharp increase in inflammatory blood markers or other blood tests may demonstrate that the disease is becoming more active.4 While blood tests like sedimentation rate (ESR) and c-reactive protein are not always accurate indicators of disease as some RA patients tend to not show high results5, they can serve as some gauge of disease activity and are used for clinical trials for drug development. If the level of general inflammation in my body is increasing while taking certain medications, it may be a sign that they are not working well.
Many side effects of RA medications are tolerable. But sometimes side effects can have too great of an impact forcing one to make a change in medication. One biological medication I was taking caused my cholesterol, blood sugar, and blood pressure to skyrocket. This side effect was listed as a possibility. The side effects, coupled with the lack of impact on my RA, were enough for my doctor to pull me off of the drug and move onto another option.
Others around you
Sometimes we can’t see the “forest for the trees” so to speak and we need others to observe how we are doing. I will tend to put my head in the sand and march on like nothing is wrong. As the British say, “hold a stiff upper lip” or “keep calm and carry on.” I’m fortunate to have a wife who can observe changes over time and call it like it is. She usually questions the efficacy of a drug combination if she senses it is not working.
Too many RA patients stay on a treatment combination that is not effective and in the long run, they needlessly suffer and waste precious funds. If you don’t feel that your RA is under control, perhaps it's time to consider making treatment plan switch.
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