So, What's New in 2010 For Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune-based disease that affects approximately two million Americans. The pathogenesis seems to implicate both genetic as well as environmental factors.

The chronic inflammatory response leads not only to joint destruction but also to damage involving internal organs.

Because of the complicated nature of the disease, no one therapy has been found to be curative.

In the early 1980's methotrexate revolutionized our treatment approach to rheumatoid arthritis. Prior to methotrexate, patients had limited options. Among them were gold salts, d-penicillamine- a highly toxic medicine, and hydroxychloroquine (Plaquenil).

What really allowed rheumatologists to achieve remission though was the development of highly targeted biologic therapies in the mid-1990's.

So... the upshot is that RA treatment has progressed rapidly with the introduction of biologic drugs such as the TNF-inhibitors (Enbrel, Humira, Remicade, and more recently, Simponi and Cimzia), rituximab (Rituxan), and abatacept (Orencia).

These drugs have greatly improved the quality of life for RA sufferers.

A number of new studies presented at the American College of Rheumatology meeting in Philadelphia has shed some light on predictors.

The first example is a study demonstrating that patients having a rapid response to Cimzia were more likely to have long-term control of disease.

Another study showed that patients with very high levels of rheumatoid factor, a protein that is elevated in the blood of 80 per cent of patients with RA predicted a better response to Remicade.

Another paper showed that older patients, particularly those with more aggressive disease had less of a response to TNF-inhibitor therapy than those patients who were younger and had milder disease.

Another study showed that restarting TNF-inhibitor therapy after loss of remission was effective in regaining remission. This paper was quite controversial in that most practitioners have found just the opposite to be true.

One study demonstrated that patients intolerant to TNF-inhibitor treatment were more likely to respond to Rituxan than they were to another TNF-inhibitor.

A significant predictor of x-ray progression of disease were two markers: rheumatoid factor positivity and age.

One encouraging paper showed that between 35 per cent to 50 per cent of patients who began treatment with biologics stayed on the same biologic for an extended period of time, sometimes many years.

The same meeting produced a study that expressed the idea that patients who were treated with a combination of methotrexate plus a biologic were more likely to stick with the biologic than if they were treated with the biologic alone.

Other studies showed that "small molecule" drugs... drugs that can be taken orally but which have biologic effects are promising.

Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis Treatment Center (http://www.aocm.org). He is a former Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: Arthritis Treatment

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