Stopping therapy, he said, will become a goal for RA treatment. “When I meet patients, the common thing they say to me, is, ‘How long am I going to be taking the drug for?’ ” Dr. Emery recalled. “If you say, ‘for the rest of your life,’ it’s not the most encouraging thing to a patient. And so the question is, ‘How can we possibly have transient use of drugs?’ ”
The first step, he says, is to get to patients early in the course of their disease. The second is getting them to a normal maintenance of function and quality of life with normal immunology. Achieving the latter will likely involve more aggressive treatment early in the course of disease.
“In the future, we’re going to be using TNF [tumor necrosis factor] inhibition early but not late,” he said. “I don’t think TNF inhibition is a great drug late, partly for the reason I said about MTX, the incremental benefit is less, there is already structural damage, and there is a limit to what you can achieve because the amount of inflammation that is mediated by TNF actually reduces over time.”
Dr. Emery presented data from the COMET (Combination of Methotrexate and Etanercept in Active Early Rheumatoid Arthritis) study, which compared the impact of MTX alone with MTX in combination with etanercept. The study showed that, after one year, about 50% of patients treated with etanercept plus MTX were able to achieve remission, compared with 28% treated with MTX alone.
He also noted that the BeST trial, showed that the ability to discontinue combination therapy was better achieved in patients who received biologics as initial therapy.3
During his presentation, Dr. Emery also asked the questions: What happens when you give a biologic later in disease? Can you stop it? To answer them, he showed data from two studies. One study was PRESERVE [Maintenance, reduction, or withdrawal of etanercept after treatment with etanercept and methotrexate in patients with moderate rheumatoid arthritis]. The bottom line of this study, he said, is that patients who start biologic treatment late don’t maintain the response well when etanercept is stopped, but they do better when the dose is halved.
The second, the CERTAIN study, showed that when patients who started treatment late stopped taking adalimumab, most of them relapsed.4
“The message is very clear: You can stop a biologic if you start it early, but it’s very difficult to stop it if you start it late,” he said.
Prevention
According to Dr. Emery, another major advance in RA will be preventing the disease altogether. “I say that without a shadow of a doubt because the data is already there,” he said.
