Biologic agents for rheumatic diseases—complex therapy mandating expert oversight

Biologic agents for treating rheumatic diseases (and other systemic inflammatory diseases) can be very efficacious and life altering; they can allow return of a normal quality of life, and prevent disabling and irreversible deformities. However, these agents carry the risk of serious adverse events, including life-threatening infection, and they are also very expensive.

In British Columbia, biologic therapy for treatment of rheumatic disease can only be initiated by a rheumatologist (and a few approved general internists who meet specific criteria). While any physician licensed to practise medicine can legally renew these prescriptions, it should be noted that the authoritative BC Guideline, Rheumatoid Arthritis: Diagnosis, Management and Monitoring (developed by Doctors of BC, formerly known as BCMA, and the Ministry of Health) recommends ongoing deference to specialists in this challenging and potentially hazardous realm:

“Details of initiation, dosing and monitoring are based on recommendations made by specialists in each case.” (page 4)

The following approach is suggested by an expert group consulted by the College:

“To ensure cost-efficacy of a particular biologic therapy and to assess the risk/benefit ratio, only designated specialists should be renewing these biologic therapies. Physicians should plan ahead and ensure that their patients on biologic medications attend their rheumatologist or designated general internist for review and renewal of their prescriptions.”

In the event of a complaint, it is likely that the Inquiry Committee, based on independent expert opinion, would be critical of a non-specialist physician who failed to ensure that a patient on biologic agents received their renewals from an appropriate specialist, or a specialist who left this task to a family physician. The experts the College relies on consider the prescribing of biologics to lie outside the scope of primary care.