Dr. Deane noted the way a patient comes to attention should affect the determination of whether they are at risk. For example, an arthralgia-first approach may miss patients with mild symptoms or may identify patients who have only recently noticed and/or become concerned about symptoms but clearly have had long-standing disease unbeknownst to them. Dr. Deane further explained that patients who progress from at risk for RA to clinically diagnosed RA may have different trajectories, with symptoms progressing in a linear fashion for some and others experiencing peaks and values in joint pain until symptoms ultimately become more persistent.
An important subject that both Dr. van der Helm-van Mil and Dr. Deane discussed is weighing the risks of RA with the risks of intervention. By this they mean that if a patient is considered at risk for the disease, the clinician or researcher making this determination must decide what the next step is. Should this patient be actively treated? What are the potential side effects of such treatment? What if a patient has poor access to specialized care—in such a scenario, is the at-risk label simply superfluous? Nevertheless, Dr. Deane is hoping to build on the work of the EULAR group and use population-based approaches, such as health fair screenings, to identify at-risk patients and better understand their course over time. He did tell the audience that if they know of population-based cohorts they think would be relevant to study, they should contact him directly to discuss being a part of this project.
APIPPRA Study
The third and final speaker was Andrew Cope, MD, a professor who holds the AR UK Chair in Rheumatology, King’s College London, U.K., and he discussed the Abatacept in Individuals at High Risk of Rheumatoid Arthritis (APIPPRA) study. The aim of this study was to treat patients who were in the preclinical phase and prevent the development of RA. In the study, researchers recruited adults who had inflammatory joint pain and tested positive for antibodies to citrullinated protein antigens (ACPA) and rheumatoid factor.
The 213 participants from The Netherlands and the U.K. were then randomized to receive either abatacept or placebo for 12 months and were followed up for another 12 months. After 12 months, about 30% of participants in the placebo group had RA or inflammation in three or more joints compared with 6% of people who received abatacept. Those receiving abatacept also reported improvements in pain, well-being and quality of life, as well as less joint inflammation during treatment. At 24 months of follow up, 25% of participants in the abatacept group had developed RA compared with 37% in the placebo group. The authors of the study thus argued that therapeutic intervention during the at-risk phase of RA is feasible, although treatment beyond 12 months may be required to prevent progression.2
