Remote patient monitoring using novel technology may make it possible for rheumatologists to choose the “right drug right out of the gate,” according to data presented at the Congress of Clinical Rheumatology East.
Jeffrey R. Curtis, MD, of the University of Alabama at Birmingham, noted that a wide array of technological advances, from clinical informatics to drug selection using patient-generated data, may allow rheumatologists to better foresee which drugs will elicit the best response.
“We are going to talk about predicting the future,” he said.
To that point, Curtis suggested that the word “predict” is often used incorrectly in medicine. He noted that predicting response to a medication or treatment is an inexact science that uses imperfect data to assess what may happen to a patient.
“What we are hoping to do is to predict the right drug for the right patient at the right time,” he said. “But sadly, we don’t have that yet.”
In rheumatology specifically, clinicians usually start with one drug, and if that does not work, try another.
“The evidence is usually very low, or the recommendations are conditional,” Curtis said.
Moreover, clinical factors often are only factored in regarding the second or third drug a rheumatologist may choose.
“What are you going to reach for?” he said. “The answer is: What the insurance company tells me to reach for.”
However, technological advances may change this landscape.
“The goal is to get the right drug class straight out of the gate,” Curtis said.
For example, the PRISM RA test can help predict a poor response to a TNF inhibitor. Curtis noted that it may be counterintuitive to have a test that predicts non-response as opposed to response.
“But after methotrexate fails, most rheumatologists will reach for a TNF inhibitor,” he said. “We want a test that changes what you would actually do.”
As the PRISM test gains more widespread adoption, Curtis raised the question of whether insurance companies would allow rheumatologists to make therapeutic choices based on such findings.
“In Alabama, you can choose adalimumab [Humira, AbbVie],” he said. “If you apply for something else, you get adalimumab, and if you appeal, you get adalimumab.”
In short, the payers are directing therapeutic choices.
“Science should lead policy, and not the reverse,” Curtis said.
Additionally, Curtis argued that it is cheaper for patients to be in remission than to have ongoing relapses and flares of their disease.
“That may be the only part of the conversation that a payer may care about,” he said.
Payers, in fact, may be starting to pay attention to such advances. Certain forms of patient data collected via mobile technology have become reimbursable “as of January this year,” according to Curtis.
With this in mind, Curtis urged rheumatologists to take note of novel approaches that are currently available on the market, like devices to monitor uric acid levels for patients with gout, or “smart toilets” to collect stool information in Crohn’s disease and colitis.
“You can measure almost anything non-invasively,” Curtis said.
However, the ability to collect all of this information gives way to another question: “But what does it mean?” said Curtis.
With the technology in place, it is up to clinicians to make sense of the information and use it to clinical benefit for their patients, Curtis argued.
“If we make a patient wear a device and collect all of this data from them, we really need to use it,” he said. “It is really quite discouraging if we have patients tell us all of this information and then we ignore it.”
Curtis urged rheumatologists to not only adopt new technologies, but to tailor their use to the factors that are important to patients, like sleep or fatigue.
“It gives the patient a voice,” he said. “It doesn’t reduce them to a CDAI score.”
Written by Rob Volansky | Photo by Tima Miroshnichenko from Pexels