ReviewTight control applied to the biological therapy of rheumatoid arthritis
Highlights
► Tight control is a treatment strategy tailored to each individual patient with RA. ► Measurements of RA activity should be obtained on a regular basis. ► Information technology helps monitoring disease activity. ► US helps monitoring disease activity and facilitating interventional therapies.
Introduction
Over the last decade, treatment strategies for rheumatoid arthritis (RA) have included the administration of disease-modifying anti-rheumatic drugs (DMARDs), alone or in combination, as early as possible, since prompt suppression of disease activity is correlated with reduction in radiological joint damage [1], [2]. This strategy is now included in a broad concept of “tight control”, i.e. a treatment strategy tailored to each individual patient with RA, which aims to achieve a predefined level of low disease activity or remission within a certain period of time [3]. At the same time, tight control should include careful and continuous monitoring of disease activity, and early therapeutic adjustments or switches should be considered when necessary. A tight control strategy has been successfully applied to other chronic conditions, such as diabetes and hypertension [4]. In the treatment of RA, the early application of strategies designed to intensively suppress joint inflammation, with either conventional DMARDs or biologic anti-TNFα therapies in combination with methotrexate has allowed disease remission to become an achievable goal for a relevant number of patients, therefore leading to improved long-term outcomes [5], [6], [7]. The key role of tight control of RA has been stressed by the recent European Guidelines issued by the European League against Rheumatism (EULAR) [6].
This brief, narrative review will discuss the most recently available evidence on the role of a tight control strategy in the treatment of RA, and how this strategy should be applied, with a focus on current “hot-topics” in clinical research.
Section snippets
Monitoring disease activity
The EULAR Guidelines recommend that measurements of disease activity should be obtained on a regular basis, as frequently as monthly for patients with high/moderate disease activity, or less frequently (such as every 3–6 months) for patients in sustained low disease activity or remission [6]. However, once a patient has achieved sustained remission or low disease activity in subjects with long-standing RA, less frequent evaluations may suffice. The same Guidelines stress the importance of using
The role of information technology
Recent studies and experience support the role of information technology in helping to monitor disease activity. Salaffi et al. investigated the acceptability, feasibility, reliability and score agreement of collecting patient-reported outcome (PRO) data using an interactive touch-screen computer system [9]. In total, 87 RA patients completed both a newly-developed touch-screen system (RHEUMATISM; RHEUMA Touch-screen Italian SysteM) and a conventional paper-administered set of questionnaires.
What to do if the first biological DMARD fails?
The introduction of biologic therapies represented a major breakthrough in the treatment of chronic inflammatory autoimmune diseases, including RA [11], [12]. Despite the high effectiveness shown by these molecules in clinical practice, failure is often experienced, and may be due either to a lack/loss of response or to the onset of unbearable toxicity [11]. The optimal switch strategy is currently a matter of debate [13].
When the first biological DMARD fails, and in particular anti-TNF agents
The impact of anti-drug antibodies development on clinical effectiveness
The results of a recent long-term study on RA patients treated with adalimumab showed that the development of antidrug antibodies is associated with a lower drug concentration and a lower likelihood of minimal disease activity or clinical remission [19]. Switching to a different anti-TNF agent would appear to be an effective therapeutic choice if antibodies directed against the first agent develop. In a study by Van der Bijl et al. that evaluated 41 patients on adalimumab following the failure
Towards the future
The EULAR has stressed how important imaging techniques, such as X-rays, MRI and ultrasound are in monitoring disease progression and radiographic damage in order to maintain tight control of disease activity [23]. However, radiological follow-up is carried out only every 1–2 years by 69.5% of rheumatologists, and ultrasound and MRI are not routinely used by the vast majority of rheumatologists [8]. We feel that there is now a place for the widespread use of imaging techniques in clinical
Acknowledgements
The authors declare no conflict of interest directly relevant to this paper.
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