Improved Arsenal

Doctors now have many different weapons to fight inflammation in RA. In 1988, the disease-modifying antirheumatic drug methotrexate was approved for RA and became widely used by late 1990s. It’s still the standard first-line drug used to treat RA inflammation, says Dr. Diri.

“It’s probably the best risk/benefit drug for rheumatoid arthritis at this point, and my number one drug,” he says.  Still, if he doesn’t see results after about two months, biologic drugs – the first of which, etanercept, was approved for RA in 1998 – are added. This is a big change from the approach to RA in the past, when doctors might wait several months to see if drugs were fighting inflammation – a period when irreversible joint damage might occur, he says. “Now, patients who are diagnosed with rheumatoid arthritis start with methotrexate and we get the biologic on board if they don’t respond. We don’t hang around too much anymore.”

All of the biologic drugs work in about half of RA patients, so rheumatologists can switch the patient to another treatment if one isn’t working, says Dr. Bathon. And because the drugs are more effective and are being used earlier to fight RA inflammation, we no longer see the need for multiple joint surgeries in these patients, she adds. “People quite often had hand surgery, foot surgery, shoulder replacements, knee replacements. When weight-bearing joints were affected by RA, it was even more life-changing. If you can’t work because your hips are bad or your knees are bad, you’re on disability,” she says. However, the new array of drugs to fight inflammation, including oral, infused and injectable biologic drugs, work well enough to offer people with RA a greater chance at a normal life, she says.

The challenges for rheumatologists now include educating primary-care physicians and medical students to recognize the signs of RA early so patients can be referred for aggressive treatment before joint deformity can take place, says Dr. Diri. “When I observe students doing a rotation with me, when I mention even something like an anti-CCP (anti-cyclic citrullinated peptide antibody) test, they say, ‘Oh, is that new?’ And this student, in a few months, will be a physician! If they’re not educated about the new things in rheumatology, then they think that they can manage RA with NSAIDs or 5 to 7.5 milligrams of methotrexate a week, delaying appropriate treatment of the patient.”

In addition to better education of rising doctors on the possible signals of an RA diagnosis, rheumatologists are focusing on more effective, precise tests to not only determine RA early, but figure out which drug treatment will work best on each individual patient, says Dr. Bathon. “Research in biomarkers is key. Is there a genetic polymer? Is there a particular protein marker in the blood? That’s where the field is heading.”

Meanwhile, surgeons are seeing fewer patients with “runaway inflammatory disease” coming to see them for procedures because the current drugs work so well, says Dr. Katz, who says he sees far more osteoarthritis patients nowadays due to earlier diagnoses in that population. “The more aggressive strategy is associated with better outcomes. It’s a happy story.”