The growing availability of biologic therapies for rheumatoid arthritis and other inflammatory autoimmune disorders has had a dramatic impact on the treatment and prognosis for patients with these potentially disabling diseases.
Biologics are genetically engineered drugs designed to interact with the body’s immune response to dampen the damaging effects of rheumatologic disorders. In the case of rheumatoid arthritis, the most common of these disorders, the drugs specifically target proteins known to be involved in the joint inflammation that characterizes the disease. For some rheumatoid arthritis patients, biologics — either alone or in combination with traditional drugs — can slow the progression of rheumatoid arthritis.
“Fifty years ago, a diagnosis of rheumatoid arthritis often meant that the person would progress on to disability in a wheelchair,” says John FitzGerald, MD, PhD, interim chief of the UCLA Division of Rheumatology. “Today, with the availability of older drugs such as methotrexate and the newer biologics, we are able to put some patients into remission. While remission is difficult to achieve for many patients, in the past, it was not even a goal.”
The first biologic was approved in 1998 by the U.S. Food and Drug Administration for the treatment of rheumatoid arthritis, reducing inflammation by inhibiting the molecule TNF-alpha. Other TNF blockers soon followed, Dr. FitzGerald notes. On the heels of their success in treating rheumatoid arthritis, they were approved for other closely related rheumatologic diseases, such as psoriatic arthritis and similar inflammatory arthritidies. As the biology of these diseases became better understood, other target molecules were identified, and now several different classes of biologics have been approved. Given that no one drug is effective for every patient, having a variety of options improves the likelihood of finding a successful drug or combination of drugs.
Because the biologics are costly — generally several thousand dollars a month — they are typically prescribed only after more traditional and inexpensive drugs such as methotrexate are proven to be insufficient for a patient. Most of the biologics are administered by self-injection, although an oral form has recently been introduced. Researchers are currently seeking clues that will help to accurately predict which patients will respond best to which treatment option, but for now it is difficult to know in advance, Dr. FitzGerald notes.
Until the 1980s, the approach to rheumatoid arthritis tended to be conservative rather than aggressive, notes Veena Ranganath, MD, a UCLA rheumatology researcher and clinician. “The conventional thinking was to start with physical therapy and high doses of nonsteroidal anti-inflammatory drugs or aspirin, but to wait before even using a drug such as methotrexate,” Dr. Ranganath says. That changed, she explains, after research showed that earlier treatment with methotrexate improved overall outcomes. “Now it’s very clear that we need to decrease the inflammation sooner rather than waiting until later,” she adds, noting that aside from the disability related to the joint problems, untreated symptoms can increase the risk for cardiovascular disease and osteoporosis, as well as diseases of the lungs, skin and eyes.
The good news, Dr. Ranganath notes, is that the likelihood of successful treatment is better than ever. “We have a long way to go,” she says, “but to even be able to talk about remission illustrates that we’ve made huge strides.”