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Biologics, early treatment, and lifestyle choices take the spotlight in rheumatoid arthritis advances.
The prevalence of rheumatoid arthritis (RA) has been significantly underestimated, particularly among younger individuals, according to a new report. A potentially crippling disease, RA can be tricky to diagnose early and expensive to treat.
The report, released in Arthritis and Rheumatology in January 2018, shows that 19.3% of men and 16.7% of women aged 18 to 64, and 15.7% of men and 13.5% of women over age 65 report joint-symptoms but don’t have doctor-diagnosed arthritis. Overall prevalence of arthritis, including both diagnosed and undiagnosed cases, is 29.9% in men and 31.2% in women aged 18 to 64, and 55.8% in men and 68.7% in women over age 65, according to the report.
These estimates, gleaned from an analysis of the 2015 National Health Interview Survey (NHIS), are 68% higher than previous prevalence estimates, which relied merely on a single survey question and did not correct for measurement errors.
Treating RA takes up a huge market share for pharmaceuticals, with one RA biologic-Humira-earning the top spot as the world’s best-selling drug for several years. But as more biologics and biosimilars hit the market, it’s important to consider the big picture in RA management.
Miriam Cohen, MD, is an assistant professor of medicine at the Johns Hopkins University School of Medicine whose clinical expertise is in clinical and molecular rheumatology. She says Janus kinase (JAK) inhibitors are the big topic in RA treatment lately, and will likely be the next step in care from RNF-inhibitors “RA seems to be the one area that’s taking off with new medications and biologics,” Cohen says. “The idea is to be more selective.”
While JAK inhibitors seem to target RA very well, some concerning side effects must be addressed before more widespread adoption, she says. Side effects can be similar to old disease-modifying antirheumatic drugs (DMARDS), spurring concerns with blood counts and hepatic function. Cohen says there are also concerns with lipid levels, cardiovascular disease, and bowel issues. Cohen would also like to see an oral formulation for these medications.
One JAK inhibitor that was approved by the FDA is tofacitinib (Xeljanz), a twice-daily pill that can also be used to treat psoriatic arthritis. “It’s exciting because it’s a different approach to treatment, and involves a different arm of the immune system,” Cohen says.
Other companies are looking at the JAK 1, 2, and 3 enzymes, she says. Aside from JAK, though, she says there are also new developments with TNF- and RNF- inhibitors, as well as biosimilars.
Though there are more options than ever, Cohen says clinicians are also slower to adopt biosimilars. “There’s a lot of suspicion and wariness of how they work in terms of response and effectiveness.”
Erin Bauer, MD, is a board-certified rheumatologist practicing at Virginia Mason Medical Center in Seattle, agrees, adding that there has also been some availability and logistic problems with biosimilars. Bauer also agrees that the market for biologics will continue to grow, particularly in the area of JAK inhibitors.
More research is supporting a host of next-generation treatments for RA, with a new study out of Denmark crediting these treatments for a reduction in joint replacements in RA patients.
René Lindholm Cordtz, PhD, a rheumatology expert from Denmark, who coauthored the report in the Annals of the Rheumatic Diseases, notes that next-generation medications for RA, such as biologics, have transformed the face of the disease over the last two decades. Particularly, newer medications have improved the outlook for RA patients in terms of joint health.
His study found that since biologics were introduced to treat RA, fewer RA patients in Denmark have required total knee replacements. While new RA therapies can be costly, Cordtz says it’s important to note the savings in terms of nonmedical costs of RA (lost wages and productivity, decreased quality of life) as well as the avoided costs of joint replacement surgery.
“We hope our study motivates clinicians and patients to keep on committing to an aggressive treatment strategy including early use of biologics in case of nonsufficient effect of conventional DMARDs,” Codtz says. “Our main message is that the need for major surgeries such as total hip and knee arthroplasty has decreased among newly diagnosed rheumatoid arthritis patients in Denmark following introduction of biologics, although more aggressive treatment with conventional DMARDs and the treat-to-target strategy could also have contributed to this finding. During the same period, the use of these surgeries increased in the general population of Denmark.”
When it comes to choosing which of the many RA treatments is appropriate for a particular patient, Cohen says there are two schools of thought. One is to follow the American College of Rheumatology’s algorithm and guidelines for treatment. This option, however, doesn’t always fit a patient’s needs.
“The plan for RA is to use methotrexate or similar first. The next step for those whose disease doesn’t respond to methotrexate therapy is to move on to add a biologic, usually an anti-TNF,” Cohen says. “But the algorithm doesn’t always work because it doesn’t always fit the patient.”
The second approach is to consider the patient’s individual needs, she says.
“If a patient consumes more than a few drinks per week, methotrexate is not the medication of choice. If a woman wants to have kids, then maybe use an older DMARD like Plaquenil. Some patients may have an aversion to needles of infusions,” Cohen says. “It’s not a one-size-fits-all plan.”
Another consideration is cost, she warns.
“It sounds like the world is our oyster and we have so many medications to choose from, but that’s not the case. Often, insurance companies will tell us what a patient can use,” Cohen says.
“There’s still a lot we don’t know and need to learn about,” Bauer says. “We’re continuing to learn there’s maybe a role for preventing RA and maybe catching it early. Going forward that will really be a big area with ongoing studies.”
For example, research suggests that first-degree relatives with RA or who are positive for certain antibodies may benefit from early treatment-even before and overt diagnosis of RA, Bauer says.
“I could see that in the next year or so gaining traction,” she adds.
Another factor in the management of RA is a change in mindset for providers. In the past, RA was diagnosed by its advanced and crippling presentation. Now, suspected RA is treated early, hopefully before extensive damage occurs, Cohen says.
“In the old days, we weren’t as aggressive. We waited for the diagnosis, and we waited for radiographic proof of erosions,” Cohen says. “We don’t really want to do that anymore. By the time we see that the game is almost over.”
Rachael Zimlich, RN, is a writer in Columbia Station, Ohio.