Putting clinical care standards into action for rheumatoid arthritis, game-changing PBS approvals and CAR-T cell therapy for refractory/severe systemic lupus erythematosus are all tipped to be focuses of the specialty in 2024.

The limbic asked three leading rheumatologists for their takes on what has recently changed practice and what is about to alter the treatment landscape.

Dr Claire Barrett, ARA president and Brisbane rheumatologist

What’s something that changed practice in rheumatology in 2023?

The long-awaited change in the PBS prescription authority level from written to streamlined for most RA patients being treated with b/tsDMARDs resulted in a massive change in many rheumatologists’ practice.

Since 1 November 2023 we are not spending hours each week on unnecessary tasks, like filling in forms and phoning for lost scripts, but we can use our time to see patients.

The “freed up hours” increase access to specialist rheumatology care.

What’s something likely to shape rheumatology in 2024?

It would be easy to harp on the same note, knowing an extension of the November 2023 PBS restriction changes to all autoimmune rheumatic diseases would shape rheumatology in 2024, but, that aside, I hope the Clinical Care Standards for RA, funded by the ARA, will shape this and future years of Australian rheumatology.

The resource provides guidance to healthcare professionals so they can deliver quality care and have informed discussions about treatment options with their RA patients while setting out the components of care that health services can use to guide practice and monitor improvement in their hospitals and other services.

Professor Eric Morand, Director of Rheumatology, Monash Health and Dean of Sub-Faculty of Clinical and Molecular Medicine, Monash University

What’s something that changed practice in rheumatology in 2023?

CAR-T.

The use of CAR-T B cell depleting therapy in lupus and other connective tissue diseases literally exploded onto the scene in 2023 with a landmark Nature Medicine paper of the first cases, followed by multiple updates as the year progressed on these sentinel cases that are reported to be in drug-free remission.

Now, multiple companies are ‘piling in’ on this space and time will tell if it all pans out. Trials are open in Australia now for severe refractory lupus.

Of note, the US FDA has issued a notice about CAR-T malignancies evolving in some cases treated for lymphoma so caution is needed.

What’s something likely to shape rheumatology in 2024?

According to PBAC online disclosures the PBS listing of anifrolumab will be reconsidered in early 2024, and if approved this would be the first biologic PBS listed for lupus, coming 20 years after the revolution in RA.

There is also a chance that PBS access to Shingrix will be approved for immunosuppressed patients like ours in 2024 [which has now been backed by PBAC, story link here].

These two approvals will both be game-changers, and are even connected because herpes zoster is one of the infections that is increased with anifrolumab treatment, and prevention would be highly desirable.

Professor Rachelle Buchbinder, Head of the Musculoskeletal Health and Sustainable Health Care Units, Monash University

What’s something that changed practice in rheumatology in 2023?

• Aspirin is inferior to enoxaparin as prophylaxis against DVT post hip/knee replacement
• The Clinical Care Standards for RA developed by the ARA are great and we should do some more for other conditions
• There are also clinical care standards now developed by the Australian Commission on Safety and Quality in Health Care as well as the first WHO guidelines for low back pain that should change practice if they can be disseminated and implemented (and the updated Knee OA clinical care standards from The Commission are also to be released shortly)
• Overwhelming evidence for lack of effect of platelet rich plasma injections for OA and for tendinopathies so this should no longer be offered

What’s something likely to shape rheumatology in 2024?

• CAR-T cell therapy for refractory/severe SLE
• Would like to think use of the Australian Living Guideline recommendations for inflammatory arthritis in adults and in children