New Views on Difficult-to-Treat Rheumatoid Arthritis
Practical Pain Management reports on updates presented at the 2022 American College of Rheumatology (ACR)’s annual meeting by experts including S. Louis Bridges, Jr., MD, PhD, physician-in-chief and Chair of the Department of Medicine at HSS, and Iris Navarro-Millan, MD, rheumatologist at HSS, pertaining to rheumatoid arthritis (RA).
About 20% of people with RA fit the description of having “difficult to treat” or refractory disease, according to experts. As more is known about this subgroup of patients, potentially through evolving understandings of biology, clinicians can better treat their disease and pain.
Dr. Navarro-Millan covered definitions of difficult-to-treat-RA. ACR does not currently have a definition, but EULAR describes this as a failure of at least two or more biologics or targeted synthetic disease-modifying antirheumatic drugs (DMARDs). In addition, the management of signs and symptoms may be perceived as problematic. At least one of the following signs must be present: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and the management of signs and/or symptoms are perceived as problematic by the rheumatologist and/or the patient.
The hope, said Dr. Navarro-Millan, is to homogenize the definition, teasing out which clinical manifestations are due to inflammation that would require a decision to increase or modulate the immunosuppression.
Dr. Bridges discussed current research agenda for difficult-to-treat-RA. In patient-related factor research, there is a need to look at non-pharmacologic approaches, such as smoking cessation, diet, and multidisciplinary care. Some physician-related causes may be tied to failures of the current healthcare system, such as requiring patients to fail one drug before trying another. And in the area of disease-related factors, the number of publications related to RA (along with lupus and cancer) has increased greatly – meaning our understanding of its pathophysiology is slowly informing new treatments.
For instance, the use of artificial intelligence may soon help clinicians predict RA disease activity at future clinic visits based on information in the electronic health record, shared Dr. Bridges. He cited a 2019 study on the assessment of a deep learning model based on data that predict RA flares. While the model worked well in a university hospital, with more complete records, and better-supported patients, the same model applied to a safety-net hospital, where patients may not have all the resources they need, did not work as well. The findings indicated, he said that, “We really have to focus on the social determinants of health – all the nonbiological aspects of treatment that should be considered when we talk about RA.”
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