Where Are We with RA? Prevention, Treatment & Management Challenges

WASHINGTON, D.C.—Despite a decade of progress in rheumatoid arthritis (RA), challenges remain. Remission is drug maintained. Multimorbidity abounds, and treatment strategies can be challenging for some. And, as of yet, RA is not preventable.

At ACR Convergence 2024, Iain McInnes, PhD, FRCP, director, Research into Inflammatory Arthritis Center, professor of medicine and rheumatology, vice principal and head of College and Veterinary and Life Sciences, University of Glasgow, Scotland, shared updates on RA.

Which Biologic?

We’re fortunate to have a multitude of treatment options for RA in 2024 and have come a long way from glucocorticoids and gold. But more drugs mean more choices, and it’s still not clear which drug will work best for which patient, or best … period.

“Guidelines exist [from the ACR and EULAR], but don’t tell us which drug to use,” Dr. McInnes noted. “Our choices are driven by cost, accessibility or ‘the drug I can spell most easily’ (i.e., the drug we’re most comfortable with).”

Dr. McInnes

The 2023 NORD-STAR trial attempted to answer the question of which biologic is best. “For a patient taking methotrexate who isn’t doing so well, which is the best of the biologics? According to these data, the answer is … any of them,” Dr. McInnes summarized. “Choose the drug you know best that will be best for the patient in regard to comorbidity and cost.” Of note, in this trial, clinical disease activity index for RA (CDAI) remission rates for patients taking abatacept (59.3%) or certolizumab pegol (52.3%) were superior to those taking tocilizumab (51.9%), but by a small margin.¹

Then Dr. McInnes turned toward the PERFECTRA trial, a pragmatic, multi-center, real-life study comparing treat-to-target strategies with baricitinib vs. tumor necrosis factor (TNF) inhibitors after failure of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Baricitinib was found to be non-inferior and superior to TNF inhibitors.²

“Janus kinase (JAK) inhibitors are very efficacious in people with RA, but you need to obey the black box warning,” he said. When prescribing a JAK inhibitor, the risk of adverse events and safety profile must be taken into account. They may be safe for some, but riskier for others.³

“Can I Stop My Meds, Doc?”

Over the past few years, we’ve seen tapering studies that allow us to better answer this question. The simple answer? Maybe. But it depends on the medication.

When it comes to methotrexate, we may be able to lower the dose with concomitant use of a TNF inhibitor. “In the MIRACLE trial, the dose of methotrexate could be reduced by nearly 50% at the time of initiation of the TNF inhibitor with no difference in response compared with those who continued maximal-dose methotrexate,” Dr. McInnes said.⁴