25 Years in Arthritis: New Treatments, New Hope

Now, he said, "we have methotrexate, sulfasalazine, Arava (leflunomide), and at least eight new biologics that target four different pathways -- all approved already by the FDA. We have dozens more therapies in clinical trials. We also have methods being developed to predict response to drugs."

A patient eligible for biologics in 2009 would get an upbeat prognosis from Utz.

"I'd tell her that we would start her on an injectable or infusable biologic that blocks TNF, and that she had an [approximately] 70 percent likelihood of having a response," Utz said.

"If this failed, we'd try a different TNF inhibitor and perhaps even a third one and still could capture a response. If that failed, then we could go on to inhibitors of T-cell costimulation, or B-cell inhibitors, or IL-6 inhibitors, or IL-1 inhibitors. I'd tell her many even cooler drugs were being developed, many of which are oral."

Dr. Beth Jonas, another University of North Carolina rheumatologist, echoed the point that the outlook is still bright for patients who fail biologic treatments.

"Each patient is unique, and it is almost impossible to know up front which drug is best for each individual patient. There is a lot of 'trial and error' at this stage to find the most effective therapy," she said.

Diagnosis and Monitoring Refined

Rheumatologists also agreed that tools for evaluating RA patients had improved markedly, if not so dramatically as treatments have.

Diagnosis and monitoring had been mainly a clinical art in the 1980s. Now, said Matteson, "We've become more comfortable with more formal assessments of disease activity."

He mentioned the 28-item Disease Activity Scale, better known as the DAS-28, as a key tool for the modern rheumatologist.

"Quantitation of patient status" is now routine in rheumatology practice, Matteson said.

Von Feldt pointed out that the role of rheumatologists has itself grown dramatically. She estimated that, a quarter century ago, perhaps 10 to 20 percent of RA patients were managed by specialists.

The figure is now likely above 90 percent, she said.

Another innovation has been the introduction of ultrasound and magnetic resonance imaging to supplement X-rays for monitoring joint erosion.

Matteson said these new technologies help in detecting erosions that don't show up on X-rays.

But several of the rheumatologists contacted for this article indicated that their clinical evaluations would not have changed much. They indicated that X-rays and lab tests for such markers as rheumatoid factor, C-reactive protein, and erythrocyte sedimentation rate, along with clinical assessments, were the mainstays in 1984 and remain so today.

Von Feldt said about diagnosis and evaluation of RA, "It's still a clinical skill."

The Mounting Cost

Life is still not a bowl of cherries for RA patients. Eventual disease progression remains the rule for patients, even though, compared with earlier generations, they will be much older when joint surgery becomes their best option.

Cost of treatment, for one thing, has become a much larger issue.

The retail cost of biologic drugs starts at more than $1,000 per month, and that's for a single agent. The approval of the B-cell-targeting agent rituximab (Rituxan) for RA, which is typically added to a TNF blocker, means costs can mount even faster.

Matteson said he has a discussion of the economics of treatment with all his patients, asking about their financial means and insurance status.

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