Emerging Trends in the Treatment of Rheumatoid Arthritis Save

While I’m only 7 years into a (hopefully) long career in the field of rheumatology, the pace at which we are seeing advances in new medications and earlier detection of rheumatoid arthritis requires you to continually refresh your approach to the disease. 

 

We still haven’t displaced methotrexate and other conventional DMARDs, followed by TNF inhibitors for initial disease management. However, our approach to more difficult disease has certainly evolved over time, mostly because of the increasing number of FDA approved medications available to use. 

 

In the past year, we have seen the approval of a second IL-6 blocker with saralimumab, and a second JAK inhibitor with baracitinib. 

 

A recent study in ARD (http://dx.doi.org/10.1136/annrheumdis-2018-213378) showed that as the number of choices of biologics increases over time, we are seeing clinicians cycle through options more quickly, hoping that these patients see improvement

 

Clearly, we need better biomarkers to help us predict earlier which biologics we should be trying first for our patients. 

 

Here are the top three trends I’m seeing in rheumatoid arthritis treatment:

 

1. Aggressive treatment. In the case of rheumatoid arthritis, time spent with joint inflammation means damage (in addition to pain, sufferring, and other comorbid problems). With this in mind, we should use our biggest guns first. In many causes, our choice of biologic is due to a number of other factors (often insurance coverage and patient comorbidities), but even with these in mind we should be trying to use the medication that we think will have the best chance of inducing remission. 

 

2. Earlier treatement due to earlier recognition of disease. While newer biomarkers beyond rheumatoid factor (RF) and anti-citrullinated antibodies such as 14,3,3 eta certainly are interesting in helping recognize and risk stratify some patients with new rheumatoid arthritis, we have to remember that RA is a disease of active joint inflammation. And we have to remember that a good portion of patients with RA are seronegative, but with increased use of ultrasound, especially in the United States, we’re improving our ability to recognize early joint inflammation in cases where we’re unsure of our physical exam findings. 

 

3. Avoidance of corticosteroids. One advantage of having increasing options for aggressive treatment of rheumatoid arthritis is that we’re having less tolerance of leaving our patients on prednisone for prolonged periods of time. While steroids will continue to be a large portion of our practice, as we learn that most of the infection risk and other organ damage actually occurs because of prednisone, we’re doing a much better job of finding ways to replace it with other therapies.