Deciding to have patients resume biologic medications after they have had serious infections is one of the toughest decisions I make in practice.
A woman with rheumatoid arthritis developed Escherichia coli septic arthritis of her knee. She survived, but in view of her comorbid conditions, including severe emphysema, I was worried that she might not survive another serious infection and I told her not to go back on etanercept. I tried treating her with various nonbiologic disease modifying drugs that previously had inadequate results: As you might expect, the results were dismal. Her huge swollen joints reminded me of one of my professors with a flair for the dramatic. He would say things in clinic like, "This patient has 2 pounds of synovium in her wrist."
Toward the end, her care was largely palliative and consisted of analgesics and prednisone. Her quality of life was quite diminished because of very severe arthritis. I felt twinges of guilt and helplessness every time I saw her during the last few years of her life.
Another patient on abatacept developed an abscess in his calf. A bit of a curmudgeon, he was quite annoyed that it took the hospital doctors a few days to figure out that he had an abscess after he was originally misdiagnosed with cellulitis. My point of view was exactly the opposite, and I was impressed that the hospital doctors had arrived at the correct diagnosis so quickly.
I tried to explain that cellulitis was a common illness but that calf abscesses were rare. He reluctantly accepted my explanation, or at least he got tired of complaining about it. He is about the same age as the woman I mentioned above, but he is much more robust. Even though he is well into his 70s, he loves to play softball in various senior leagues. He spends his winters in Florida in a kind of perpetual spring training. I was worried about putting him back on his medication, but his overall health was good. If I didn’t put him back on the medication, I knew it would be the end of his softball days, and I’d either lose a patient or, worse yet, have a more-unhappy-than-usual curmudgeon in my office. I have plenty of those already.
A 65-year-old woman with RA in my practice was doing very well on methotrexate and etanercept. She too was hospitalized with septic arthritis of her knee. After she got out of the hospital, she came back to see me. She had already been off etanercept for over a month, her arthritis was getting worse, and she wanted to resume etanercept. I told her not to resume the medication because I thought it was too dangerous. I discussed other options, including adding other nonbiologic medications such as hydroxychloroquine or prednisone, or perhaps a biologic such as rituximab. She didn’t like any of these options and we remained in a standoff, so I asked her to come back in a few months.
She was due back in 2 months but she didn’t come back to the office until 5 months later. When I walked in she told me that she was much better. The nurse had written in the chart, "wants etanercept." I was confused. Why did she want to go back on the medication if her arthritis was doing so well without it? "You’ve been off the etanercept since your septic arthritis, haven’t you? You didn’t resume it, did you?"
She had resumed the medication. My immediate thought was that maybe her family doctor had refilled it for her or, worse yet, I had refilled it inadvertently during a senior moment. Seeing my bewilderment, she reassured me that I wasn’t having a senior moment.
She went on to explain why, for several reasons, she had decided on her own to resume the medication shortly after her previous visit. She had about a 4- month supply of the medication in her refrigerator (probably about $7,000 or $8,000 worth) and she couldn’t bring herself to waste it. Only carefully trained medical professionals can waste money on such a grand scale and not lose any sleep over it. She also assumed that her risk of infection would be the same with any other biologic medication.
She said that she hated to go against my advice (join the club, I thought to myself), and I couldn’t help but smile. "The doctor-patient relationship is like a three-legged race. We have to run in the same direction, or we’ll both fall down!" I told her. She liked that bit of homespun wisdom.