Expanding the Armamentarium for the Treatment of Juvenile Rheumatoid Arthritis: Update for Managed Care Pharmacists
Melanie Swims, PharmD, BCPS*
Pediatric rheumatic diseases were not recognized until the late 1800s when, in fact, pediatrics itself was a relatively new field.1 Despite this recognition, the concept of differences between adult and pediatric rheumatic diseases was not pursued until after World War II.1 In recent decades, better definitions of diseases and significant advances in therapy have enhanced the understanding of rheumatic diseases and care of pediatric patients. Improvements in imaging, laboratory studies, genome sequencing, and immunopathogenesis have facilitated the differential diagnosis of rheumatic diseases.
Juvenile idiopathic arthritis (JIA), or juvenile rheumatoid arthritis, is the most common chronic rheumatic disease in children and a significant cause of short-term and long-term disability.2 JIA encompasses a heterogeneous group of diseases, whose cause and pathogenesis are still poorly understood. Joint inflammation and radiographic destruction can occur on average within 2 to 5 years of disease onset.3 Inflammation associated with JIA involves a complex immunologic pathway with cellular mediators that have become important treatment targets against disease.4
From gold therapy to methotrexate to biologics, evolution of JIA treatment has resulted in more successful reduction of joint damage and, in some cases, radiographic changes.3 Although not yet curative, early aggressive treatment has the potential to prevent impaired joint function and control disability, which may decrease long-term health costs and improve patient productivity.4 Management for children with active disease typically requires pharmacotherapy coupled with physical therapy, occupational therapy, and psychosocial management. Children with chronic illness are more likely to experience psychological and behavioral problems, particularly with demanding medical therapies.5 Deformity and loss of functional ability associated with JIA may contribute to depression, anxiety, and adjustment problems in both patients and family members. Consequently, a multidisciplinary healthcare approach is vital to improving clinical outcomes and enhancing quality of life.
Financial burden, as well as physical and emotional burdens, should be alleviated, particularly with higher-cost therapies, such as biologics. Clinicians and family members should collaborate in making therapy decisions, while considering direct costs associated with treatment and indirect costs associated with functional ability. As a fundamental component of the US health insurance system, managed care organizations control cost of services, direct use of services, and measure quality of care. Managed care pharmacists must often make complex decisions regarding the financial effects of treatment applications on health systems, managed care plans, and large patient groups. However, managed care pharmacists can also play key roles in the management of patients with JIA by educating patients, family members, and fellow clinicians, monitoring therapeutic efficacy, and screening for potential medication adverse effects.
This issue of University of Tennessee Advanced Studies in Pharmacy is based on the proceedings from a roundtable symposium held in San Antonio, Texas, on May 16, 2008, which included educational presentations and interactive discussions intended to enhance learning through the provision of professional pearls. The roundtable participants were physicians and pharmacists with expertise in a variety of adult and pediatric practice settings, including academic, veterans affairs, clinical research, consultant, and managed care environments. This monograph, as developed by all participants, is intended to provide managed care pharmacists with practical strategies for translating the latest medical and scientific developments and applications into the best possible patient outcomes, with a focus on the managed care setting.
The monograph begins with a review of the epidemiology, pathophysiology, and clinical features of the various classification types of JIA as discussed by Linda Kay Myers, MD, of University of Tennessee Division of Pediatric Rheumatology. The second article, by Michael L. Miller, MD, of Northwestern University Feinberg School of Medicine, Department of Pediatrics, Division of Pediatric Rheumatology, provides an overview of pharmacologic strategies, with additional emphasis on a team approach of healthcare professionals and strategies to improve adherence. The third article is presented by Sheldon J. Rich, RPh, PhD, of SJR Associates, LLC, with the clinical content developed by Jake Nichols, PharmD, MBA, BCPS, of Commonwealth Medicine at the University of Massachusetts Medical School. This article focuses on the socioeconomic impact of JIA, healthcare challenges associated with therapy, and managed care concerns of insurance providers and clinicians. The final article, presented by Pete Penna, PharmD, of Formulary Resources, LLC, includes 3 case scenarios that illustrate strategies for coordinating interdisciplinary therapy with managed care concerns. Additional participants who contributed to the roundtable discussions included Darla Busbey, PharmD, of the Veterans Affairs Medical Center in Memphis, Tennessee, Assil Saleh, MD, MPH, of The Johns Hopkins Hospital Division of Rheumatology, and myself serving as Courser Director, Melanie Swims, PharmD, BCPS, of the Veterans Affairs Medical Center in Memphis, Tennessee.
With a greater understanding of immunologic pathways and the advent of biologic therapies, the management of JIA has changed dramatically in the last decade. With continued research, refinement of definitions, and availability of consensus treatment guidelines, the prognosis of children with JIA will continue to improve. The partnership of healthcare professionals and managed care organizations will benefit patients, clinicians, and health insurance providers.
1. Schaller JG. The history of pediatric rheumatology. Pediatr Res. 2005;58:997-1007.
2. Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369:767-778.
3. Passo M. Emerging therapies in juvenile rheumatoid/idiopathic arthritis. Curr Probl Pediatr Adolesc Health Care. 2006;36:97-103.
4. McCann LJ, Woo P. Biologic therapies in juvenile idiopathic arthritis: why and for whom? Acta Reumatol Port. 2007;32:15-26.
5. Turkel S, Pao M. Late consequences of chronic pediatric illness. Psychiatr Clin N Am. 2007;30:819-835.
*Associate Professor, Department of Pharmacy, University of Tennessee, Clinical Pharmacy Specialist, Ambulatory Care, Veterans Affairs Medical Center, Memphis, Tennessee.
Address correspondence to: Melanie Swims, PharmD, BCPS, Veterans Affairs Medical Center, Department of Pharmacy, 1030 Jefferson Avenue, Memphis, TN 38104. E-mail: firstname.lastname@example.org.
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.