Dispelling the myths of early RA
SAN DIEGO — Challenging accepted treatment paradigms may lead to better outcomes in early rheumatoid arthritis, according to findings presented at the 2019 Congress of Clinical Rheumatology West.
Janet E. Pope, MD, MPH, division head of rheumatology at Western University, Schulich School of Medicine and Dentistry in London, Ontario, Canada, wanted to address fallacies regarding what may or may not be done for patients with early RA.
In particular, Pope’s talk covered prevention, managing pre-RA, whether there is a window of opportunity to treat, and how aggressive treatment of early RA can or should be. But she was realistic about many, including the first, of these possibilities. “There is a myth that we can prevent RA,” she said. “Prevention of RA is really not ready for prime time.”
In addition to traditional approaches like weight loss and smoking cessation, Pope also briefly raised the possibility of vaccination as an RA prevention strategy. “In terms of anti-ACPA vaccination, it is difficult to know if this will work,” she said.
Screening is another potential way of identifying patients earlier, but the time and money required to screen the general population remain huge hurdles. “We are not ready to screen the asymptomatic population,” she said. “It can be useful for research, but it is not an obtainable goal.”
Pope then turned her attention to the use of biomarkers in identifying and managing early RA. “There is a myth that biomarkers will help us in RA,” she said. “In general, we do not have the test that will give us that ‘a-ha’ moment and tell us the patient will have this disease.”
Moreover, biomarkers have not shown a consistent ability to predict who will have drug-resistant disease, who is likely to progress faster or slower, and who will sustain significant joint damage. “We just don’t know any of that yet,” she said.
While the multibiomarker disease activity (MBDA) has shown some efficacy in predicting joint damage, and 14-3-3n may have utility as a predictor of radiographic progression, the extent to which they add clinical value is still up in the air. “Every biomarker comes and goes,” Pope said.
Pope then moved on to treatment, raising the question of whether there is a window of opportunity to put patients with early RA into remission. In general, she encouraged early, aggressive treatment. “Methotrexate monotherapy in early RA is not a big winner,” she said. “Two-thirds of patients who undergo this therapy fail to achieve sustained remission. Why do we have guidelines that tell us to give methotrexate monotherapy?”
Another argument for early treatment is that longer symptom duration is associated with a lower chance of DMARD-free sustained remission. “This suggests that there is, in fact, a window of opportunity,” she said. “I argue for strong treatment at the outset, because I think the American College of Rheumatology and EULAR guidelines are insufficient. We should be doing more than that in early RA.” – by Rob Volansky
Pope JR. What do we really know about early RA? Presented at: Congress of Clinical Rheumatology West. Sept. 25-29, 2019; San Diego.
Disclosure: Pope reports consulting, or conducting research, with Actelion, Amgen, AbbVie, Bayer, BMS, Genzyme, GSK, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, Regeneron, Sandoz, Sanofi and UCB.