A study of almost 12,000 patients using data largely from Medicare and Medicaid found that the rate of serious infections for anti-TNF agents was incrementally increased by a fixed absolute difference, regardless of age, comorbidities, and other factors that contribute to infections. Higher rates of infection were seen for new infliximab users compared to new etanercept and adalimumab users.1
The more serious the disease, the greater the risk of infection, as well, Dr. Silman said. One study found that the Disease Activity Score (DAS) bore a relationship to the infection risk.2
In a patient with a high DAS, not only do physicians need to think about suppressing the disease activity, but they also need to consider that these patients are at the highest risk of developing a serious infection, Dr. Silman said. In his talk, Dr. Klareskog said it’s important not to lump together comorbidities into one bundle, but to distinguish between those that run parallel to RA, those that seem to be causes of RA, and those that are consequences of RA treatment.
Each category, and each type of comorbidity, calls for individualized action.
“They can be of many different kinds, and I think that we should keep them apart because there are different consequences and different measures that we could take,” he said.
Dr. Klareskog talked about the progress of identifying early lung abnormalities in patients who later develop RA—although it is not known yet how these abnormalities and RA are linked.3
“This is a disease that may be parallel,” he said. “It may also be causative to RA.” More attention needs to be paid to what happens in the lungs in the early stages of RA, he said.
Connecting Pain and Inflammation
Dr. Klareskog also drew attention to the emerging understanding of the separation between pain and inflammation. Reducing inflammation frequently does not lessen a patient’s pain.
“It’s not enough to take away the inflammation—you have to continue with pain treatments,” he said. “And that may be one of the major reasons why patients who get…treatment for inflammation actually don’t go back to work and still have decreased quality of life.”
One recent study found that anti-TNFs have distinct effects on pain and inflammation, acting to reduce pain rapidly. Researchers suggest that neutralizing TNF-α affects nocireceptive brain activity in arthritis, before it achieves antiinflammatory effects in the joints, which might explain its earlier-than-expected effects.4
Dr. Klareskog issued a special warning that rheumatologists need to take early action against cardiovascular risk in RA patients. A recent meta-analysis found that there is a 1.5- to 2-fold increase in cardiovascular disease risk for patients with RA.5
