Jessica Walsh, MD: Patient Perspectives of Biologic Treatments for Axial Spondyloarthritis

Rheumatology Network spoke with Jessica Walsh, MD, to discuss her study, “Patient perspectives of biologic treatments for axial spondyloarthritis: satisfaction, wear-off between doses, and use of supplemental medications,” which was presented at the EULAR 2021 Virtual Congress. Walsh is a medical advisor for CreakyJoints and is affiliated with the University Utah School of Medicine and George E. Wahlen Veteran Affairs Medical Center. She gives a brief summary of the study design and results, explains why most patients experience wear-off between biologic doses, and the importance of understanding a patient’s experience of their treatment.

Rheumatology Network: Hi, Dr Walsh, thank you for joining me today.

Jessica Walsh, MD: Hello, it's a pleasure to be here.

RN: To begin, why is understanding a patient's experience of biologic disease-modifying antirheumatic drug (DMARD) therapy is so critical for rheumatologists treating this patient population?

JW: Patients experience their diseases a little bit more globally, I think, sometimes than providers think about and so understanding how patients perceive their therapy and what their goals are is important. And understanding where the gaps are between what the providers and the patients want is very helpful. For example, I think a lot of times providers think in terms of specific disease features. Their tendon disease is active or inactive, or their joints are active or inactive, whereas the patient kind of takes it all together and may think about it more in terms of “I'm in pain, or I'm not in pain” more so than what specific features might be involved.

RN: Can you tell me a bit about the study design?

JW: Yes. So, this is a survey study, a cross sectional survey. So, patients were invited to participate via CreakyJoints, a platform where patients are invited to give information and also learn about their diseases. And they self-report what their disease state is in there. There are questions about who their rheumatologist is and what their symptoms are to help us better understand their disease. And then they answer a lot of survey questions. And then we look at those and report on the outcomes.

RN: And what were the results of the study?

JW: So, for this study, we were looking at biologics and patient satisfaction, disease activity, particularly in regards to the medication wear-off between doses or waning efficacy between doses. So, we wanted to know how frequently this was occurring and whether wear-off was associated with satisfaction and disease activity. And we also looked at what other medications patients use when they were reporting wear-off of their medications and their biologic medications.

RN: Did their results surprise you?

JW: Oh, not particularly. Well, actually, let me take that back. The frequency of patients reporting wear-off was pretty high. Over 60% of patients said that they experienced waning efficacy between their doses. And, I think, clinically we hear patients talk about that a lot. But I was still somewhat surprised that it was as high or as frequent as we've learned in the study.

RN: Why do you believe that most of the patients with axial spondyloarthritis experience wear-off between doses causing them to reach for other medication options in the interim?

JW: That's a great question. It’s a little bit inconsistent with what we know or what we think we've learned from clinical trials and from pharmacokinetic information. Patients apparently frequently say, though, in the last day to 3 days, 4 days before the dose that their symptoms get worse. And I don't know that I understand clinically why that is happening. But you know, it's a consistently reported issue that's affecting patients’ disease activity and quality of life.

RN: In your opinion, is there any way to mitigate treatment dissatisfaction and the use of supplementary treatments for these patients?

JW: I think this can be approached from multiple angles. Obviously, it would be great if there was an answer to why these medications are wearing off. Is it as simple as we need to change the dosing schedules? So, if it's an every 2-week medication, maybe it should be every 12 days or every 7 days. We would obviously need more data to better understand if that's the right approach. From a from another standpoint, is it appropriate and recommended to reach for supplemental pain management, medications and/or non-pharmacological treatment? I think the answer to that is obviously, yes. For some people experiencing the disease that might be exercise or therapy. Sometimes people may use meditation more. But you know, a lot of patients in this study are using medications and non-steroidal anti inflammatories were very commonly reported to be used, particularly when patients were experienced the wear-off. Muscle relaxants were commonly used. Interestingly, about 37/38% reached for opioids to help cope with the wear-off experience, glucocorticoids were used in about 20%, cannabinoids were used in about 20%. So, there's a lot going on that the patients are associating with this wear-off or using to cope with it. And I think we need to better understand what is occurring before we can know how to appropriately improve wear-off and support patients in their management of the wear-off.

RN: Were there any strengths or limitations of the study that you'd like to address?

JW: The population of the study is a little bit interesting. One of the strengths is that it's predominantly female. Historically, axial spondyloarthritis has been studied much more frequently in males. It's exciting to have a more female predominant population. It's also patient reported diagnosis, so we need to keep that in mind. This might not be the most representative export population since the demographics are different than what we're used to seeing in other studies. But I do think it's exciting. Of course, it's cross sectional and there's always issues with not understanding what's going on in the longer term, recall bias, and all sorts of issues when we're looking at cross sectional patient reported surveys. But overall, I think it's a fairly unique study that's helping us understand, or getting starting to understand, a frequently encountered problem that we see in clinical care.

RN: Does your team plan on doing any further research on this topic?

JW: Yes, I think so. I don't think all the plans are completely laid out yet, but I there's a lot of interest from both the provider and research side, and also from the patient side. So, I do think we'll dig a little deeper.

RN: Is there anything else that you'd like to add about this study or axial spondyloarthritis before we wrap up?

JW: I think in general, I'm very pleased and honored to be involved in more patient-centered research and learning about perspectives that are a little bit different than provider perspectives and what we see in clinical care. I think we need to do a lot more work with this. And I am happy that this particular topic is getting some traction, because it's just something that I talk about so much in clinic with patients on a day-to-day basis.

RN: Dr Walsh, thank you so much for speaking with me today.