What’s driving the DAS? A rheumatoid arthritis decision-making framework

This article has been funded by Galapagos Biotech Ltd. Galapagos supported the nurse education and hosting of the discussion which led to the development of the algorithm. The content of the algorithm was developed by three rheumatology nurse leaders (Alison Kent, Brian Rhys-Dillon and Julie Painter) based on their clinical experience and expertise.  

Galapagos has a product, Jyseleca▼ (filgotinib), that is reimbursed for treating active moderate rheumatoid arthritis patients in the UK. The full indication, links to prescribing information and adverse events reporting can be found at the end of the article.

Supporting shared decision making with patients who have moderately active rheumatoid arthritis

To improve long-term health outcomes for people living with rheumatoid arthritis (RA) it is imperative to get active disease under control as soon as possible, minimising irreversible damage to the joints (Aletaha and Smolen, 2018).

Advanced therapies are now available earlier in the treatment pathway than before, marking a crucial addition to the treatment toolkit for people with moderate RA (National Institute for Health and Care Excellence (NICE), 2021a; NICE, 2021b; NICE, 2021c; NICE, 2021d). However, complexities in identifying which moderate RA patients could benefit from an advanced therapy means that many people are still not accessing treatments that could help them achieve remission (Pan et al, 2019).

What is the DAS algorithm?

The Disease Activity Score (DAS) algorithm has been developed to help rheumatology professionals decipher ‘What's driving the DAS?’, supporting them with identifying moderate RA patients who should be considered for an advanced therapy (Rhys-Dillion et al, 2023). The user-friendly tool was initiated and developed by three advanced rheumatology nurse leaders with a cumulative experience of over 70 years and is designed to support other clinical rheumatology professionals, irrespective of experience, in shared decision making around moderate RA management plans (Rhys-Dillion et al, 2023). This algorithm was accepted as a poster and presented at The British Society for Rheumatology (BSR) conference in 2023 (Rhys-Dillion et al, 2023).

Why was the algorithm developed?

Advanced therapies have been available to patients with moderately active RA, as well as for those with severe forms of the disease, for decades across Europe, including the Republic of Ireland. However, eligibility restrictions in the UK have meant that, until recently, only patients classified to have severe RA (DAS >5.1) could access advanced therapies under the NHS. As a result, many patients living with moderate RA have not been benefitting from these treatments, despite being shown to experience profound difficulties in everyday living with RA (Nikiphorou et al, 2021).

Importantly, though, in 2021 NICE revised their guidance in response to findings from clinical trials demonstrating that advanced therapy provides similar benefits for patients with moderately active RA as well as for those with severe forms of the disease. Patients in the UK with a moderate RA DAS (>3.1 - <5.2) are, therefore, now permitted to be treated with advanced therapies on the NHS (NICE, 2021a; NICE, 2021b; NICE, 2021c; NICE, 2021d).

This guidance hallmarked a positive milestone in shaping an improved treatment landscape in RA, helping patients to access the most appropriate treatments required to best support their burdensome symptoms (Rhys-Dillion et al, 2023). However, optimal care for patients with RA remains blocked by several factors.

First, it is important to not rely solely on the DAS. Not all moderate RA is the same, and there can be substantial heterogeneity between patients presenting with a moderate DAS (Pan et al, 2019). Moreover, since the DAS is a composite measure of subjective endpoints, it can give a false impression of true disease burden, with some moderate patients having active disease and others not (Pan et al, 2019).

In a similar vein, interpretation of an elevated DAS may be further confounded by the presence of comorbidities (for example, fibromyalgia or osteoarthritis) (Pan et al, 2019). To ensure correct diagnosis for patients and cost-effective use of resources, it is essential to be precise when identifying a moderate RA patient requiring additional treatment escalation due to active inflammatory joint disease (Rhys-Dillion et al, 2023).

Beyond the potential for a misleading DAS, the BSR have recognised two more, closely related unmet needs in the rheumatology landscape: the need for succession planning and a wider, appropriately skill-mixed rheumatology nursing workforce (BSR and  National Rheumatoid Arthritis Society (NRAS), 2019).

The BSR report, entitled Specialist Nursing in Rheumatology: The State of Play (2019), described rheumatology nurse specialists as an ‘aging workforce’, with 60% of survey respondents being aged 50 years or over, indicating that many rheumatology nurses were due to retire in the next 15 years (BSR and NRAS, 2019).

Aiming to address these challenges as longstanding members of the nursing community, Alison Kent, Brian Rhys-Dillon and Julie Painter sought to develop a resource compiling their expertise. The nurses hope that the algorithm will help facilitate peer-to-peer support and the sharing of knowledge between existing and newer nurses, in order to support clinical decision making for all nurses, regardless of experience, and ultimately benefit this subset of patients under limited and valuable resources within the NHS (Rhys-Dillion et al, 2023).

How does the algorithm work and how can it be used in clinic?

The algorithm is a structured and standardised way to evaluate the implications of a patient’s DAS and help identify whether they are presenting with active disease (Rhys-Dillion et al, 2023). The framework provides various prompts to consider when examining a patient, guiding the rheumatology professional to the next, most appropriate step depending on the outcomes (Rhys-Dillion et al, 2023).

Rheumatology nurses play a central role within the RA community, from their increasing involvement in individual treatment decision making, to their evolving contribution towards optimising patient outcomes in RA.

By providing a user-friendly and freely available decision-making framework, the algorithm intends to empower rheumatology nurses to feel more confident in deciphering between moderate patients with active disease warranting potential treatment escalation and those whose moderate disease is driven by non-inflammatory factors, who may benefit from exploring alternative treatment plans (Rhys-Dillion et al, 2023).

As such, endorsement and dissemination of the DAS algorithm as an education tool should be promoted in an attempt to aid daily practice for all clinical rheumatology professionals (Rhys-Dillion et al, 2023).

How was the algorithm developed?

In an educational workshop for rheumatology nurses, hosted by Galapagos, Alison, Brian, and Julie vocalised their vision of sharing their knowledge with the rheumatology nursing workforce to allow for continued quality of care as part of the succession planning programme. In alignment with their longstanding commitment to promoting peer-to-peer education within the RA nursing community, Galapagos were pleased to be able to support their vision by facilitating their coming together within roundtable discussions.

Within these discussions, the nurses were able to draw on their varied rheumatology experience and relevant publications over a 12-month period, helping them to develop their decision-making algorithm for use by the rheumatology community in daily practice (Rhys-Dillion et al, 2023).

In the longer term, the algorithm represents a reassuring step in the efforts to provide longstanding guidance, knowledge and support to the next generation of nurses working within the rheumatology workforce (Rhys-Dillion et al, 2023).

References

British Society for Rheumatology, National Rheumatoid Arthritis Society (2019) Specialist Nursing in Rheumatology: The State of Play. BSR.

Electronic Medicines Compendium (2023) Jyseleca SmPC. medicines.org.uk (accessed 11 October 2023).

National Institute for Health and Care Excellence (2021a) Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed. nice.org.uk, 14 July (accessed 11 October 2023).

National Institute for Health and Care Excellence (2021b) Filgotinib for treating moderate to severe rheumatoid arthritis. nice.org.uk, 24 February (accessed 11 October 2023).

National Institute for Health and Care Excellence (2021c) NICE recommends several treatment options to help thousands with moderate rheumatoid arthritis. nice.org.uk, 10 June (accessed 11 October 2023).

National Institute for Health and Care Excellence (2021d) Upadacitinib for treating moderate rheumatoid arthritis. nice.org.uk, 10 November (accessed 11 October 2023).

Nikiphorou E et al (2021) Disease impact of rheumatoid arthritis in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society. Rheumatology Advances in Practice; 5: 1, 10.1093/rap/rkaa080.

Pan Y et al (2019) Not all moderate disease is the same – identification of disability trajectories among patients with rheumatoid arthritis and moderate disease activity. PLoS ONE; 14: 5, e0215999.

Rhys-Dillion B et al (2023) British Society for Rheumatology Annual Conference 2023 Abstracts. Abstract citation ID: kead104.161. Rheumatology; 62: suppl 2, kead104.161.