CME/CNE/CPE

Advances in Management of Early Rheumatoid Arthritis: Where Are We Now, and Where Are We Going?

Rene Westhovens, MD, PhD

Catholic University of Leuven
Leuven, Belgium

The questions below were submitted by your peers based on a recent CME/CNE/CPE activity.
The Course Director, Dr. Rene Westhovens, provides his answers below.

Question 1: I have just begun treatment for RA. Will this be a lifetime treatment and progression of drugs?

Question 2: What are the indications for treating RA, and is there such a thing as "burned out" RA? Should an asymptomatic patient be treated?

Question 3: Is there a time limit for the benefit obtained with biologic therapies?

Question 4: I have a patient who is on omalizumab for asthma. Is this a contraindication to using adalimumab or other biologic for RA?

I have just begun treatment for RA. Will this be a lifetime treatment and progression of drugs?

The evolution of RA is not easy to predict, but remissions without taking medication are rare. The current therapeutic principles include early intensive treatment—sometimes with a combination of medications—to achieve remission, followed by a maintenance therapy with fewer drugs to maintain this remission. This is a reversed pyramid approach, which is currently preferred above a classical pyramid approach that always comes too late with the more powerful and effective drugs.

What are the indications for treating RA, and is there such a thing as "burned out" RA? Should an asymptomatic patient be treated?

Indications for treatment include not only decreasing inflammation and symptoms but also preventing joint damage and loss of functionality and quality of life. Even in refractory, longstanding RA, there is often still inflammation that can respond to drug treatment. When a patient is asymptomatic, one mostly thinks about having a patient without pain. When there is still joint swelling, the chance of future joint destruction is still there, and a patient should be treated to control the disease.

When there is no inflammation at all and when there is no progression of joint damage or functional decline, a treatment is tapered to find the minimal effective dose to maintain control over the disease.

Is there a time limit for the benefit obtained with biologic therapies?

Most biological therapies are very effective, but data from registries demonstrate that every year about 10% of patients on a certain biologic stop this treatment because of lack/loss of efficacy or because of side effects—and sometimes because of a combination of both. Many patients, however, have prolonged effects of a regular administration of TNF blockers or abatacept. A drug such as rituximab needs a repeat dose after a mean of 8-10 months.

I have a patient who is on omalizumab for asthma. Is this a contraindication to using adalimumab or other biologic for RA?

There are no scientific data to judge this combination. TNF blockers are associated with an increased infection risk in many patients, and patients with asthma are also at risk for pulmonary infections. In general, the combination of biologics in other situations has been shown to increase infection risks in patients. So, this might be a dangerous combination, although no formal data exist in the medical literature.