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Prof Paul Emery : advances in treatment of rheumatoïd arthritis

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Advances in the early treatment of rheumatoid arthritis




Hello! You’re on MD-FM INSIGHT, the first medical web radio. Today we’ll be devoting our "Question & Answer" program to the latest advances in the early treatment of rheumatoid arthritis.

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In rheumatoid arthritis, new “diagnostic and treatment strategies” have completely changed disease prognosis in recent years. We met with Paul Emery, Professor of rheumatology and head of the academic section of musculoskeletal-medicine at the Institute of Molecular Medicine in Leeds. He is also a leading researcher in the early treatment of rheumatoid arthritis.


Hello Dr. Emery. First of all tell us what have been the main advances so far in the treatment of rheumatoid arthritis?

Emery 1: “Rheumatoid arthritis has seen a large number of advances: classification criteria have improved so we can diagnose it earlier. Perhaps the biggest advance is the realization that it's a continuum from a phase which is pre-clinical, to a late phase which becomes very damaging, and that this continuum can be interrupted with effective therapies. And perhaps, most excitingly the early phase of disease can be interrupted by relatively simple manoeuvers.  So a great deal of time and efforts are now spent on identifying patients from primary care who have the markers that will predict progression of disease.” 


And there’s also been progress made in understanding the immunological mechanisms at play, hasn’t there?

Emery -2: “What we know now is that the immunology is abnormal for  up to 10 years before clinical diseases are apparent, and some antibodies anti-CCP, now called ACPA, which is a group of citrullinated auto-antibodies, are present for a period, and then increase significantly just before patients get the disease. rheumatoid factor was the old antibody used. Once you have the disease, ACPA and rheumatoid factor are roughly equivalent, but the great advantage of ACPA is it’s very specific, with about 98% going on to get arthritis.” 


Ok and in one of your studies, you’ve been using this antibody to detect patients who will develop rheumatoid arthritis?

Emery-3: “We’ve been looking at people who had the antibody but no significant arthritis. Some of them just had joint pains. We imaged them with MRI and ultrasound, we did other antibodies, and then we looked to see what happened in the next few months. And what we now know is that patients who progress to inflammatory arthritis in the next six months have different imaging and different immunology to those patients who maintain a stable status but still have the antibody. So therefore, for the first time, we can actually have a population we can identify who will get the arthritis in the next 6 months that will enable us to intervene. That’s the next step.” 


And have you intervene?

Emery-4: “Well, for the moment we haven't had ethics to intervene but it's likely that the relatively safe drugs can be use at this early stage. There are data for methotrexate stabilizing disease and preventing progression. There’s a bit of data for hydroxychloroquine and there are some data for a drug called abatacept, which is a co-stimulation blocker and we will know the full results with much biggest study relatively quickly.” 


And what do you use imaging for?

Emery -5: “We use ultrasound to pick up subclinical disease and it’s quite clear that patients with the antibodies do have subclinical disease. We therefore have a measure against which we can look to see the effectiveness of early therapies pre-disease.” 


So what would be your message to doctors for their practice?

Emery-6: “I think there is no doubt that if you are at risk of arthritis, you should be assessed at the best centers as rapidly as possible. The result that we’ve seen are so good now that it may be hard to improve on even earlier diagnosis, but if we are looking to actually switch off the disease then the time to do it is before you get significant synovitis.” 


Ok and what drugs can be used at these early stages?

Emery-7: “The simpler disease modifying anti-rheumatic drugs work quite well in early disease, but gradually loose their effect. We now have a number of biologic drugs which seem to be able to work when these other simpler drugs have failed. These target single cytokine, or cells, or co-stimulation. What is also interesting is using these powerful drugs very early and see if the whole process can be switched off. So combination of the old DMARDs and the new monoclonals are being used in a variety of ways to profoundly affect the disease.”


And finally: what do you envision for the future?

Emery-8: “I think that the standard of care now suggest that one half of all new patients should be in remission at the end-of-the-year. And what we would like is to make that near eighty or ninety percent, and have a much higher proportion stay in remission of therapy. That's what patients want. They all say: how long do I have to take therapy for? To be able to say to them “you have a 50% chance of not taking therapy long term” would be a revolution compared to the previously fatal disease of rheumatoid arthritis.” 



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