Professional society guidelines might be a source of guidance and could be consulted if available; however, the American College of Rheumatology does not differentiate among TNF inhibitors.4
Finally, practical issues should be considered. What are the costs of the different treatments, and is cost a consideration for your patient? If there is a significant differential, it should be discussed with your patients.
Ultimately if it turns out that treatment with infliximab is in your patient’s best interest, where is the best place for her to receive it? Is a hospital infusion center more convenient to her home, or will the hospital add on a facilities charge, increasing the cost of the treatment? Does your office practice bill for such services?
Little or no consideration should be given to your secondary interests in the selection of a TNF inhibitor. For example, recouping the capital investments made in the infusion center or conducting income-generating activities (such as continuing to see patients) that can proceed in parallel with infusions should not play a role in the decision-making process.
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Finally, you should consider that the patient and the physician are not the only stakeholders in such decisions. All things being equal, the price of self-injection is less than infusion therapy because the costs associated with the infusion are eliminated. With the cost of healthcare a widely appreciated national problem, both the physician and the patient have an obligation to use the most cost-effective treatment.
Selecting a therapy for a patient is a complex process. A shared decision-making approach, in which patients are fully informed of the potential risks, benefits, and costs of agents and their alternatives, is always the best road to take. As long as your patient’s best interests are considered first and foremost, you are most likely to be on firm footing.
Dr. Kitsis is director of bioethics education and a member of the rheumatology division at Albert Einstein College Medicine in the Bronx, N.Y. Dr. Meltzer is assistant professor of medicine at Thomas Jefferson University in Philadelphia. Dr. MacKenzie is associate professor of clinical medicine and public health at Weill Cornell Medical College, Hospital for Special Surgery in New York.
References
- 42CFR § 411, Subpart J.
- Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009:6.
- Dixon WG, Hyrich KL, Watson KD, et al. Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy: Results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis. 2010; 69:522-528.
- Saag KG, Teng, GG, Paktar NM. American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis. Arthritis Rheum. 2008; 59:762-784.
