“Therapies that switch off inflammation have this interesting differential effect—by switching off inflammation they’re advantageous, by switching off the drive to the liver they change the lipid profile. And at the moment, the jury strongly suggests that it’s more important to switch off the inflammation,” Dr. Emery said.
Data are just beginning to show that the RA therapies are beneficial in terms of CV risk, he said. “It’s quite clear the mortality is improving on these therapies and it’s almost certainly due to the improved cardiovascular profile,” he said.
For established RA, it may not be wise to withdraw the biologic.Overall, withdrawal in patients will lead to flares in the vast majority of the patients. This is different in early disease.
—Josef Smolen, MD
Early Diagnosis of RA
With early diagnosis being so important, the rise of early arthritis clinics has been a big step forward, Dr. Emery said. “Early arthritis clinics, I’m pleased to say, are now worldwide”—including in South America and the Middle East, he said. The 2010 ACR/EULAR Classification Criteria for RA mean that the more clear-cut classification of newly presenting patients will help lead to earlier diagnoses. “You’re going to be diagnosed with RA very, very much earlier,” he said.
“The new criteria have been incredibly important for major advances,” Dr. Emery continued. “They can allow new licenses as well, because [earlier identification of RA] will, I think, allow different drugs to get licensed for new diseases.” He noted that, while synovitis plays a big role in the criteria, it can be difficult to diagnose.
Dr. Emery emphasized the value of imaging in early arthritis patients. A 2010 study found that, in seronegative patients, the probability of developing inflammatory arthritis was just 6%, but with certain clinical and radiographic features considered together, the probability was boosted to 30%—even 94% when certain ultrasound features were present.7
In a final note, Dr. Emery stressed the importance of using predictive tools in small samples of patients to better direct larger trials. He also highlighted the problem with studies against placebo.
Biologics
In his review of biologic therapies, Dr. Smolen began by saying that the EULAR management guidelines do not suggest biologics as a first-line treatment in the early stage of RA.
“It is fair to state that nothing [other] than [a] combination of methotrexate plus glucocorticoids is better at this stage of the disease,” he said “Biologics come into place when this therapy fails.” But, he said, progress has been made with many therapies targeting the IL-17 cytokine, as well as IL-6 and IL-20.
