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The Science Behind TNF Cycling: Current Research and Recommendations

Advancing the Management of Rheumatoid Arthritis: Applying Evidence-Based Strategies to Improve Patient Outcomes
Launch Date:
December 22, 2015
Expiration Date:
The accreditation for this activity has expired.

Primary Audience:

Rheumatologists; internal medicine physicians with a secondary in rheumatology; physician assistants (PAs); nurse practitioners (NPs); and nurses in rheumatology

Relevant Terms:

Rheumatoid arthritis; TNF inhibitors; DMARD therapy; biologic therapy

Martin Bergman, MD

Martin Bergman, MD
Clinical Associate Professor of Medicine
Drexel University School of Medicine Philadelphia, PA
Chief of the Division of Rheumatology
Taylor Hospital
Ridley Park, PA

Dr. Bergman is Clinical Associate Professor of Medicine at Drexel University College of Medicine in Philadelphia and is Chief of the Section of Rheumatology at Taylor Hospital in Ridley Park, PA. He has been in private practice for over 25 years and has published extensively on the use of disease measurement tools in the treatment of rheumatic diseases. As an active national and international lecturer, he has had the opportunity to present lectures on topics ranging from the history of drug development and treatment modalities in rheumatic diseases, to how to interpret statistical data.

Gregg Silverman, MD

Gregg Silverman, MD
Professor of Medicine and Pathology Director of the B Cell Immunobiology Laboratory
New York University School of Medicine
New York, NY

Dr. Silverman is Professor of Medicine and Pathology, and Director of the B Cell Immunobiology Laboratory, at the NYU School of Medicine. He leads a well-funded laboratory program that focus on the pathogenetic and protective roles of B cells in autoimmunity and inflammatory diseases. Dr. Silverman is a member of the American Society for Clinical Investigation, the Henry Kunkel Society, and the American College of Rheumatology Committee on Research. At NYU, Dr. Silverman serves as a lecturer in multiple courses for the Sackler Gruate School, the Immunology Training Program and the NYU Department of Medicine.
1. Identify the appropriate use of newer therapies for RA management based on recent trial data
2. Identify all approved first-line therapy options for patients with RA
3. Evaluate patients to ensure tight control of RA symptoms
4. Implement strategies to switch medications in patients who fail to respond initially to a regimen or whose symptom control decreases after an adequate initial response

Presented by 
Jointly provided by:

This activity is supported by educational grants from: Eli Lilly and Company, Genentech Inc, and Pfizer Inc.

Method of Participation
Participants should review the activity information, evaluate the cases, and complete the online pre- post-test and evaluation. Upon successful completion of the online test and evaluation form, you will be directed to a Web page that will allow you to print your certificate of credit. 
Statement of Need
In the absence of a cure for rheumatoid arthritis (RA), the goals of therapy for all patients remain reduction of signs and symptoms, prevention of radiologic progression and subsequent disability, and improved quality of life. Available therapies include TNF alpha inhibitors, the interleukin-1 receptor antagonist anakinra, the selective T cell costimulation modulator abatacept, the CD20-directed cytolytic antibody rituximab, and the interleukin-6 receptor antibody tocilizumab, and the Janus kinase inhibitor tofacitinib.
Clinicians face clinical challenges with respect to choosing appropriate treatment regimens for individual patients. Some patients fail to respond to initial treatment with a selected agent (primary treatment failure).  Other patients improve initially with a treatment regimen but experience a loss of response over time. Options for patients with inadequate response to TNF inhibitors include the use of alternate TNF inhibitors, non-TNF biologics, or tofacitinib. Some of these agents may be used as monotherapy, reducing risk for side effects of methotrexate. However, clinicians should be aware of and carefully evaluate the monotherapy studies involving these agents. This educational program provides evidence-based information in an accessible format for clinicians, with the overall goals of increasing clinician’s confidence and skill in adopting newer treatment approaches including options following TNF failure and monotherapy with biologics that have mechanisms of action other than TNF inhibition.
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Rutgers, The State University of New Jersey, and Global Academy for Medical Education, LLC. Rutgers, The State University of New Jersey, is accredited by the ACCME to provide continuing medical education for physicians.
Rutgers, The State University of New Jersey, designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity
Rutgers, The State University, Center for Continuing and Outreach Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission On Accreditation. Provider Number P173-12/12-15.
This activity is awarded 2.50 contact hours (60 minute CH).
Nurses should only claim those contact hours actually spent participating in the activity.
Disclosure Declarations
In accordance with the disclosure policy of Rutgers and to conform with ACCME and FDA guidelines, individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of nonprofit or government organizations and non-health care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.

Faculty Disclosures
Martin J. Bergman, MD
Dr Bergman has received grant research support from: AbbVie Inc, and Genentech. He has also been a consultant for: AbbVie, Amgen, Bristol-Myers Squibb, Celgene Corporation, Genentech, Hoffmann LaRoche Ltd, Janssen Biotech, MedImmune, LLC, Pfizer, and UCB Inc. He has been on the speaker’s bureau for: AbbVie and Celgene. And a stock shareholder with: Johnson & Johnson, Merck, and Pfizer.
Gregg Silverman, MD
Dr. Silverman has received grant research support from: National Institute of Health, American College of Rheumatology, Rheumatology Research Foundation. He has also been a consultant for: Pfizer Inc., Eli Lilly and Company, and Hoffmann-LaRoche Ltd.

Peer Review Statement
In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, CCOE has resolved all potential and real conflicts of interest through content review by a nonconflicted, qualified reviewer. This activity was peer-reviewed for relevance, accuracy of content, and balance of presentation by:  Ashraf Raslan, MD, Rheumatology Fellow (PGY-5), Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ and Claudia Carron, MSN, RN, Staff Nurse, Educator, Point of Care Coordinator, Pathology, Rutgers Robert Wood Johnson Medical, New Brunswick, NJ. Dr. Raslan and Ms. Carron have no relevant financial relationships to disclose.
Field Testers: This activity was pilot-tested for time required for participation by: Physicians:  Shreya Patel, MD, Steve Draikwicz, MD, Daniel Grabell, MD. Nurses: Geraldine Bocchieri, RN, BSN, Kathleen Brown, LPN, Carol Ruland, RN. The field testers have no relevant financial relationships to disclose.
CCOE Staff: Tristan Nelsen, MNM, CMP, and Elizabeth Ward, MSJ, have no relevant financial relationships to disclose.
Global Academy for Medical Education Staff: Sylvia H. Reitman, MBA, DipEd; Mike LoPresti, Shirley V. Jones, MBA; and Josh Kilbridge have no relevant financial relationships to disclose.
Off-label/Investigational Use Disclosure
This activity does not contain information of commercial products/devices that are unlabeled for use or investigational uses of products not yet approved.  
This continuing education activity was developed from interviews with the faculty. The faculty acknowledge the editorial assistance of Global Academy for Medical Education and Josh Kilbridge, medical writer, in the development of this program. Neither the editors of Rheumatology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporters, Global Academy for Medical Education, Rutgers, or of the Publisher.
Copyright © 2015 by Global Academy for Medical Education, LLC, and its Licensors. All rights reserved. No part of this activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the Publisher. Global Academy for Medical Education, LLC will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this activity, including any claims related to the products, drugs, or services mentioned herein. Developed in the United States of America.
Provider Contact Information
Please direct content or CE related questions or concerns to CCOE at 973-972-4267 or email ccoe@ca.rutgers.edu.
Contact Information for Technical Questions
Please direct technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email info@globalacademycme.com.
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