'New concepts' could rouse rheumatoid arthritis management out of the 'doldrums'
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SAN DIEGO — Rheumatoid arthritis has received less attention than other diseases in recent years, but some “new concepts” may rouse it from its current “doldrums,” said a speaker at the 2024 Congress of Clinical Rheumatology West.
“We have ended up in some doldrums in rheumatoid arthritis,” Arthur Kavanaugh, MD, a rheumatologist and professor of medicine at the University of California, San Diego, told attendees. “However, there are some new concepts we are dealing with — additional ways to get additional benefits for our patients.”
According to Kavanaugh, one concept pertains to stromal cells and fibroblasts, which have been studied in early trials.
“We think they are important, but we just do not know how to target them for clinical benefit,” he said. “There is still more to do.”
Another concept that has received attention recently is the possibility of early treatment. “One area where RA is taking the lead among diseases is treating early disease,” Kavanaugh said. “If you treat earlier, you should have a better outcome.”
Traditionally, RA is not treated until the disease has been established, according to Kavanaugh. However, researchers have identified potential early indicators of disease, including rheumatoid factor (RF), C-reactive protein and anti-citrullinated protein antibodies (ACPAs).
That said, not all patients with these early indicators of disease go on to develop RA. The RA community is “getting a sense” of who may develop the disease based on studies of these factors, but the picture is not clear, according to Kavanaugh.
“It becomes a challenge and an ethical issue,” he added. “The earlier you treat them, the more likely you are to treat people who are never going to develop rheumatoid arthritis.”
Meanwhile, in one cutting-edge approach, investigators have begun to study the presence of autoantibodies in the sputum to determine who may develop RA over time.
“Any autoantibody in the sputum puts them at greater risk for RA development,” Kavanaugh said. “It is satisfying in that it makes sense that expression of autoantibodies in the sputum might have some relevance to who will develop the disease.”
However, these data require further validation and are not yet ready for prime time, he added.
The uncertainty surrounding predictive factors, autoantibodies and the novel sputum data also can be found with novel RA treatments, according to Kavanaugh.
“We have lots of therapeutic options, but we still do not have great ways to tell which medicine will benefit which patient,” he said.
Despite these concerns, Kavanaugh reported that is encouraged by the flood of biosimilar products in the marketplace.
“The rules for interchangeability have changed,” he said, noting that a decade ago, rheumatologists “railed against” insurance carriers switching medications without consulting the doctor or the patient. “With biosimilars, there is so much data that says we really cannot object to them doing that.”
Predicting response to therapies is another frontier brought about by so many new medications. Early evidence points to gender, BMI or other factors as indicators of who may respond to TNF inhibition, according to Kavanaugh.
“Maybe we need to do this with different therapies,” he said.
Similarly, clinicians have difficulty choosing the next class of agents after one therapy has failed.
“We do not have a lot of data that says this patient would be better treated with drug B and this patient would be better treated with drug F,” Kavanaugh said. “We do not have personalized medicine.”
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Kavanaugh A. What’s New In RA? Presented at The Congress of Clinical Rheumatology West; Sept. 26-29, 2024. (hybrid meeting).
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