Rapid advances propel polymyalgia rheumatica care and research
The field of rheumatology is constantly in flux.
As I look back over my career, I see periods of calm within individual disease areas where progress was slow, far from occurring within the blink of an eye. Rheumatoid arthritis in the 1980s and ‘90s moved very slow (think RA and NSAIDS pre-methotrexate), but with the introduction of biologics the study of RA, and especially its care, has been transformed into something previously unrecognizable.
Similar advances have occurred in many of our other diseases. Take for example the entire field of vasculitis, which one generation ago had no randomized, controlled clinical trials, and was managed by a small handful of dedicated clinicians scattered across the world. Now, there is a palpable increase in vasculitis centers across major institutions throughout the world, and the therapeutic pipeline is bright.
I won’t even begin to discuss the rapid pace of change in psoriatic arthritis and spondylarthritis, but I think you know what I mean.
Enter polymyalgia rheumatica, the subject of this month’s round table by an outstanding group of clinicians, including Bhaskar Dasgupta, MD; Sebastian E. Sattui, MD, MS; Tanaz A. Kermani, MD; and Kenneth J. Warrington, MD; who we deeply thank. It is interesting to note that PMR has long been a disease of great interest to rheumatology practitioners, but up until recently was cared for in a non-standardized way, greatly influenced by where and with whom you trained. We are now squarely in an area of rapidly advancing evidence-based practice, as well as witnessing exciting advances in research into pathogenesis, clinical assessment and especially therapy.
Rheumatology is no different than any other medical subspecialty regarding how the focus on individual diseases appears largely based on advances in biomedical research, especially therapeutics. Consider the collaborative forces between care providers, clinical and basic researchers, and the biomedical industry, all of whom at any given time are making variable contributions to any given disease state.
For rheumatology prior to the mid-1990s, the pace of therapeutic advances was barely palpable. After all, methotrexate, glucocorticoids and hydroxychloroquine were inexpensive drugs and still the mainstays of therapy. However, with the introduction of biological immune-based therapies, for which rheumatology has led the way, the ground under our feet instantly shifted.
Although we are acutely aware of the perils regarding conflicts of interest with industry, which must be monitored and accounted for, let us be candid that without our partnership with the biomedical industry, this ‘tsunami’ of clinical trials, the advances in disease pathogenesis, and our capacity to attract energetic and well-trained clinicians and researchers into our field would all be a shadow of what they have become.
Giant cell arteritis and PMR are no different in this model. It was only less than a decade ago when GCA broke out as a disease treated not only with the historical mainstay of glucocorticoids, but also now in concert with IL-6 inhibition. Multiple drugs are now rapidly advancing in this space, and the future is bright for our patients.
Similarly, it is clear that much of the current advances in our understanding of PMR’s immunobiology have been influenced by the first steps already taken in GCA. As a result of these forces, there is now newfound interest in the disease, which is already influencing our capacity to diagnose, monitor and treat. In the end, such rapid advances must translate into quality medical education for both physicians and advanced practitioners who care for these patients, a challenge that must be met by all stakeholders.
With PMR, a disease that up until now was often diagnosed and managed by non-rheumatologists, new care pathways are warranted not only to secure accurate diagnoses, but also to bring the benefits of newer therapies that may be superior to previous standards and attended by less toxicity.
Yes, sitting back and looking at our profession over my career — in terms of transforming rheumatology into that cutting edge subspecialty dealing with immune-mediated inflammatory diseases — has been a lot of fun. Perhaps rheumatology will lead yet again the next revolution in immune-mediated inflammatory diseases, which may be the achievement of immunologic reset with the introduction and proliferation of CAR T-cell studies now underway.
That’s my take. What’s yours? Please share your thoughts with me at calabrl@ccf.org, rheumatology@healio.com or on X (formerly Twitter) at @LCalabreseDO.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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