5 Top Takeaways From the Rheumatology Conference for People With Rheumatoid Arthritis
1. Ultra-Low Dose Rituximab Controls Disease Activity for Most RA Patients
What’s new Rituximab, a monoclonal antibody, is registered for treating RA at the dose of 2x1000 milligrams (mg) per six months. In previous studies, 1x1000 mg or 2x500 mg per six months were equally effective. The new study, an extension of previous studies, found that even lower doses may be effective for many people living with RA. Research details In a previous study, doses of 200 and 500 mg of rituximab appeared to provide a similar benefit to those of 1,000 mg, but the researchers were unable to prove that statistically. In this extension study, conducted at Sint Maartenskliniek Rheumatism Center in the Netherlands, 118 patients in the previous trial were included with an approximate follow-up of three years. The rituximab dose per infusion was 200 mg in 37 patients, 500 mg in 47 patients, and 1,000 mg in 34 patients. The final interval between infusions was around six months. Why it matters Patients on ultra-low doses did not do better than those on higher doses in terms of disease activity. But patients on ultra-low doses didn’t do worse, either. The benefits are significant. In the original trial the team found fewer infections in the lower-dose group. “We think it is likely that a lower dose does not suppress the immune system as strongly as higher doses do. This way, the body can fight off pathogens more easily to stop or prevent infections,” says Nathan den Broeder, a PhD student at Sint Maartenskliniek Rheumatism Center in the Netherlands and the study’s coauthor. Other “less is more” benefits included reduced infusion times and lower treatment costs.
2. Health Benefits of Statins for People With RA Outweigh Increase in Diabetes Risk
What’s new Statins are widely prescribed to reduce the risk of cardiovascular disease (CVD) by lowering cholesterol. There has been some concern, however, that this class of drugs slightly increases type 2 diabetes risk. A recent study looked at whether this minor increase should be of concern for people with RA who are already at a higher risk of type 2 diabetes. The result: Statins were associated with important reductions in CVD and all-cause mortality in people with RA, outweighing the risk of type 2 diabetes. Statin use was associated with a 32 percent reduction in CVD, a 54 percent reduction in all-cause mortality, and a 33 percent increase in type 2 diabetes risks, which is only slightly higher than the risk among the general population. Research details The researchers analyzed medical records of people in the United Kingdom who were age 18 or older, diagnosed only with RA, and who had been prescribed one or more disease-modifying antirheumatic drugs (DMARDs) between 1989 and 2018. The study included 1,768 statin users and 3,528 nonusers who were followed for rates of CVD and mortality, and 3,608 statin users and 7,208 nonusers followed for rates of type 2 diabetes. Why it matters “We believe the benefits of statins outweigh this slight increase in diabetes risk. We hope our findings will encourage all physicians taking care of RA patients to assess for statin initiation and improve this care gap and consequently CVD and mortality in this patient population,” says Gulsen Ozen, MD, a rheumatologist at University of Nebraska Medical Center in Omaha and a coauthor of the study, adding, “We also think that this is an opportunity to address type 2 diabetes risk factors in RA patients such as obesity or activity level [and] glucocorticoid use, which we all know have other important health effects.”
3. Cycling JAK Inhibitors Is Effective for People With Difficult-to-Treat RA
What’s new Janus kinase inhibitors (JAK inhibitors), the newest class of RA drugs approved by the U.S. Food and Drug Administration (FDA), are used mainly in people with hard-to-treat RA. Each JAK inhibitor works in a different way, which affects their efficacy and safety profile. During clinical development, they were effective in RA patients who failed therapy with traditional treatments, but it was unknown which was the best strategy to adopt when treatment with JAK inhibitors fails. “Nowadays there are two possibilities in this scenario: to use another JAK inhibitor or to use a biologic drug. That is what we addressed in our study: which would be the best option after treatment failure with a JAK inhibitor,” says Manuel Pombo Suárez, MD, PhD, a rheumatologist at Hospital Clinico Universitario of Santiago de Compostela in Spain, and the study’s coauthor. Dr. Pombo Suárez presented information showing that people with RA who discontinued use of one inhibitor and then tried a second type of inhibitor had a success rate on par with that of switching to a biologic DMARD. Research details This study looked at 708 people with RA who failed a first JAK inhibitor and then were treated with either a second JAK inhibitor (cycling) or a biologic DMARD (switching) in routine care: 154 cycled and 554 were switched. Why this matters “From our data, after failure with JAK inhibitor, both strategies, to use another JAK inhibitor or a biologic drug can be effective. It is necessary to look further into this. Studies with larger sample size, longer follow-up, and including the most recent JAK inhibitors are necessary to clarify the situation,” says Pombo Suárez.
4. Active Monitoring of TNF Inhibitor Medication Is More Effective in Controlling Disease
What’s new New research proposes that therapeutic drug monitoring, in which patients’ blood samples were tested regularly to check drug serum levels in order to adjust dosage and intervals, was more effective than standard therapy with infliximab, a tumor necrosis factor (TNF) inhibitor. Drug serum is the amount of a specific drug found in blood at the testing time. Standard therapy involves no therapeutic drug monitoring and drug dose is based on the medication characteristics or clinical judgment. Research details Researchers ran a randomized, controlled, open-label multicenter trial in which 458 patients were treated with infliximab with either therapeutic drug monitoring (TDM) or with standard therapy for around 30 weeks. Participants had rheumatoid arthritis, spondyloarthritis or psoriatic arthritis (PsA). Patients in the monitored group had their infliximab dose and treatment intervals carefully adjusted to keep serum drug levels within the range of 3 to 7 milligrams per liter (mg/L). The standard group had their infliximab dosing and intervals adjusted according to the doctor’s recommendation. During the 52-week follow-up, sustained disease control without disease worsening was achieved in 167 patients (73.6 percent) in the TDM group compared with 127 patients (55 percent) in the standard therapy group. Why it matters “Keeping the drug level within the therapeutic range (and not below) helps [with] disease control [and] prevents development of antidrug antibodies,” says Silje Watterdal Syversen, MD, PhD, a rheumatologist at Diakonhjemmet Hospital in Oslo, Norway, and the study’s author.
5. Abatacept Improves Subclinical Arthritis in People at High Risk of RA
What’s new Subclinical arthritis is a precursor of the disease, in which people have biomarkers in their blood, such as rheumatoid factor or anticyclic citrullinated peptide (CCP) antibodies that indicate they have the disease, but they haven’t shown any signs of joint inflammation yet. A new study suggests that the medication Orencia (abatacept), an immunomodulator, improves subclinical arthritis in people at high risk of full-blown RA, and that early intervention may prevent or at least delay the onset of RA. Research details The study, known as ARIAA, was sponsored by University of Erlangen-Nürnberg Medical School in Germany. It looked at whether intervention with DMARDs or biologics might delay the onset of rheumatoid arthritis. In 14 different study sites, a total of 98 patients with subclinical RA were treated with either abatacept or a placebo for six months, and then were followed up for a year with no treatment. The results were that 61 percent in the abatacept group improved in at least one area (synovitis, tenosynovitis, and osteitis), while only 31 percent of the placebo group did. In addition, 17 people in the placebo group developed arthritis while only 4 people did in the abatacept group. Why it matters This study demonstrates that abatacept has the potential to improve early signs of arthritis in people at high risk of developing RA, posing the possibility that early intervention may prevent or delay RA onset. In his presentation at ACR 2021, Juergen Rech, MD, of the University Clinic Erlangen in Germany, told attendees: “Abatacept is superior to placebo in improving subclinical inflammation in RA at-risk patients and in inhibiting the progression to arthritis at six months. Use of abatacept in RA at-risk patients is safe, and no new safety issue emerged. We know that was also significant at 18 months, which means six months of treatment will delay or even prohibit that development of RA after 18 months.”
