Precision medicine provides vital ‘checklist’ to individualize patient therapy
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An increasing number of predictive biomarkers, along with deeper understanding of “-omics” like genomics and metabolomics, is pushing rheumatology closer to treatment using precision medicine, according to a recent presentation.
“The future of precision medicine is a journey that we are on,” Grace C. Wright, MD, PhD, president of the Association of Women in Rheumatology, told attendees at the at the 2020 Association of Women in Rheumatology National Conference. “It is very important for us to think through the heterogeneity we are faced with when treating our patients. A major weakness of our current treatment is that we lump when we need to separate.”
Wright discussed a number of approaches that will improve the sensitivity and specificity in diagnosing and treating such a heterogeneous patient population. “We need different kinds of biomarkers,” she said. “We have a number of patients who are refractory to any given therapy, or every given therapy, but we have no way to predict that response.”
Wright noted that there were 62 publications about precision medicine in 2019, the most of any year to date. In addition, researchers now routinely publish data on factors and biomarkers such as protein tyrosine phosphatase non-receptor type 2 (PTPN2), anti-CarP antibodies, anti-citrullinated protein antibodies (ACPA) and the 14.3.3 eta protein, among others. “These are things coming out of the research world that will improve sensitivity and specificity,” Wright said.
Increased understanding regarding what Wright termed as the “-omics” is another critical step toward precision medicine. “We have genomics, proteomics, metabolomics, epigenomics and pharmacogenomics,” she said. “That allows us to put a tag on the checklist of every way that that person is an individual.”
All of these novel approaches can complement mainstays such as rheumatoid factor (RF), sedimentation rates, cyclic citrullinated peptide (CCP), C-reactive protein (CRP) and synovial biopsy. “Some of these may be visible 15 years before [disease] onset,” Wright said. “The change in immunology starts a long time ago. There is a change. This checkpoint has been breached.”
While technology can assist clinicians in making more accurate diagnoses and treating toward more specific targets, Wright encouraged attendees also to pay attention to the fundamental characteristics of patients — everything from their age, weight and gender to their psychosocial situation and their beliefs about health and medications. Mainstay techniques such as joint exam or simple observation can still be applied toward the goal of precision medicine, as well.
“We also know that smoking is a key component why a particular person, in response to their environment, may switch to expressing their disease,” she said. “Also, if we see a patient with stiffness and malaise, that disease started a long time ago and should be treated as such.”
To that point, Wright challenged the conventional wisdom that 2 years is the optimal window of opportunity to accurately assess a patient and begin treating to target. “What if we say it is 6 weeks,” she said. “There are studies looking at that. The window is a lot tighter and smaller than we think.”
With regard to treatment, Wright encouraged attendees use a blend of scientific advancement and basic health strategies. She suggested that using biomarkers to predict which patients are likely to progress can allow clinicians to put patients on a healthier track earlier in the course of disease. “Can we disrupt disease progression with healthier diet and more exercise?” she said.
In closing, Wright challenged rheumatology to keep pace with other specialties that have been using precision medicine for far longer. “We are running to catch up with oncology,” she said. “Watch out for these papers and presentations that are mapping a way to get a better sense of who our patients really are.”
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Wright G. Exploring Precision Medicine in Rheumatoid Arthritis. Presented at: AWIR National Conference; August 13-16, 2020; (virtual meeting).
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