Biomarkers have been an important addition to the toolbox of rheumatology healthcare providers, which was illustrated in my interactions with G.H., a recent patient of mine with rheumatoid arthritis (RA).
When I met with G.H. for the first time, she told me that her disease activity had been stable on etanercept for approximately 10 years. She reported daily morning stiffness of less than 30 minutes and, aside from ankle pain which had been going on for years, complained of no other notable symptoms.
Though her symptoms seemed stable and she had limited complaints, I thought I might be able to help even these somewhat mild symptoms lessen or go away entirely, and so I told G.H. about the Vectra DA, a multibiomarker disease activity score. She had never had a recorded elevated C-reactive protein or erythrocyte sedimentation rate, and our practice therefore had no true measurement of how her disease was progressing except for what she was telling us.
G.H. agreed to the Vectra DA test. Somewhat surprisingly, her result was 60, which correlates to a high level of disease activity (a score above 45 is indicative of a high level of activity). After receiving this result, I called G.H., and she finally admitted that the etanercept was no longer working and had not been for “some time.” When I asked her why she didn’t say anything to me about this during her most recent visit, she said, “I don’t like change, and I remember how bad I felt before I started the etanercept. I don’t want to feel like that again.” I told her that it was dangerous to let her disease be poorly controlled, reminding her that her RA was not just affecting her joints, but that the inflammation could also affect her organs and increase her risk of cardiovascular disease.
After our discussion, G.H. agreed to switch from etanercept to adalimumab. However, one month later when she returned for an initial check-in, she told me she had not yet started taking the adalimumab. I was exasperated. “Why?” I asked her. She said her co-pay was going to be too high if she started on adalimumab and that she would rather just stick with the etanercept. We then had another discussion about payment assistance and eventually got her a co-pay card for adalimumab. This time, she did start the medication.
Our RA patients frequently stop their medications without telling us. In one recent study of Canadian pharmacy records, 37% of patients stopped taking their first biologic medication within six months of starting it, many times for socioeconomic reasons.1 In addition, patients are often not adherent to methotrexate regimens, yet do not admit they are not taking their medications or are taking only partial doses due to fear or embarrassment.
Without the Vectra DA, I would never have known that G.H. had a high level of disease activity, and she would likely still be silently suffering on etanercept. Rheumatology healthcare providers need to be detectives in finding the true story and real reasons that patients may not be achieving remission. Newly available tools such as the MBDA add another option to establish disease activity and even track medication adherence.
AUTHOR PROFILE: Iris Zink, MSN, NP, is a nurse practitioner at the Beals Institute in Lansing, Michigan, and the President of the Rheumatology Nurses Society.
- Choquette L, Laliberte MC, Desjardins O. Biologic discontinuation in rheumatoid arthritis: experience from a Canadian clinic. Presented at the 2014 American College of Rheumatology Annual Meeting. November 14-19, 2014; Boston, MA. Abstract 499.