Understanding emerging treatment paradigms in rheumatoid arthritis

Abstract

Treatment strategies for rheumatoid arthritis (RA) will continue to evolve as new drugs are developed, as new data become available, and as our potential to achieve greater and more consistent outcomes becomes more routine. Many patients will find both symptom relief and modest control of their disease with disease-modifying antirheumatic drugs (DMARDs), yet this course of therapy is clearly not effective in all patients. In fact, despite strong evidence that intensive treatment in the early stages of RA can slow or stop disease progression and may prevent disability, many patients continue to be managed in a stepwise manner and are treated with an ongoing monotherapy regimen with DMARDs. There is now a large body of evidence demonstrating the success of treating RA patients with anti-TNF therapy, usually in combination with methotrexate. As a result of the increased use of anti-TNF therapy, treatment paradigms have changed - and our practice is beginning to reflect this change. In the present review, we summarize the salient points of several recently proposed and emerging treatment paradigms with an emphasis on how these strategies may impact future practice.

Figure 1

Traditional treatment paradigms. DMARD, disease-modifying antirheumatic drug; HCQ, hydroxychloroquine; MTX, methotrexate.

Figure 2

Infliximab rapidly normalizes C-reactive protein levels in rheumatoid arthritis[5]. AUC, area under the curve; CRP, C-reactive protein; MTX, methotrexate. Reproduced with permission from [5].

Figure 3

Four treatment strategies of the BeSt analysis [4].

Figure 4

Clinical outcomes in the BeSt study. Error bars indicate 95% confidence intervals. DAS44, disease activity score in 44 joints (DAS44 ≤2.4 indicates adequate clinical response; DAS44 <1.6 indicates clinical remission). ACR20/ACR70, 20%/70% improvement according to the American College of Rheumatology response criteria [4]. HAQ, Health Assessment Questionnaire. Reproduced with permission from [4].

Figure 5

Some patients enter complete remission with combination therapy[41]. DAS44, disease activity score in 44 joints.

Figure 6

Less radiographic progression with infliximab combination therapy[41]. SHS, Sharp–van der Hiejde score.