Rheumatoid Arthritis Treatment: Latest and Greatest — Web Column
Reported November 30, 2005
By Harriet Edleson, Ivanhoe Health Correspondent
(Ivanhoe Newswire) — For the more than 2 million who Americans suffer from rheumatoid arthritis, there are new ways to treat its symptoms and slow down the progression of the autoimmune disease, even stop it.
Rheumatoid arthritis is a chronic, progressive disease that causes pain, stiffness, swelling, and can limit the movement and functioning of the joints. Certain cells in the body’s immune system malfunction and attack healthy joints. Inflammation primarily strikes the synovium or lining tissue of the joints. At worst, RA can be crippling. Its exact cause is still not known.
Diagnosis and treatment can be confusing for both doctor and patient. “There isn’t one thing that works for everybody,” says Eric Matteson, M.D., professor of medicine at the Mayo Clinic College of Medicine, Rochester, Minn. Treatment can be a trial and error process; if a medication fails to work, others are tried or used in combination.
Treatment begins with non-steroidal anti-inflammatory drugs (NSAIDs) such as Motrin and Aleve to reduce pain and stiffness. These over-the-counter medications improve quality of life but don’t change the course of the disease.
Edward Keystone, M.D., associate professor of medicine at the University of Toronto, explains that treating moderate to severe rheumatoid arthritis — which can be leave a person unable to get out of bed upon awakening — requires a “pyramid of therapy.” Upon diagnosis, physicians add disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage and destruction, and loss of movement. The most popular is methotrexate. When it fails, physicians add another type of DMARD called TNF-alpha (tumor necrosis factor) blockers. These so-called “biologics” inhibit the cytokine or cell protein that acts as an inflammatory agent in rheumatoid arthritis. Among them are Humira and Remicade, typically prescribed with methotrexate, and Enbrel, taken without it.
Corticosteroids can be used, too, such as injections of cortisone into the joints or prednisone taken orally. For patients who do not respond to any combination of these drugs, below are several of the newest treatments:
Abatacept: Marketed under the trade name Orencia, it appears to relieve pain and increase mobility among patients who have tried other drugs unsuccessfully. A six-month multicenter international clinical trial found patients were more than twice as likely to have significant improvement with abatacept than with standard therapy. Abatacept is the first of a class of drugs called co-stimulation blockers, which selectively impede one of the two signals needed to activate T cells, believed to play a major role in the development of rheumatoid arthritis.
A study reported in the Sept. 15, 2005 issue of the New England Journal of Medicine said after six months of treatment, half of the patients taking abatacept showed at least 20 percent improvement compared with one of every five taking the placebo at 89 sites around the world. Of the patients, 258 received abatacept as an intravenous injection while 133 received a placebo.
The Food and Drug Administration (FDA) arthritis advisory committee has recommended it for approval by the FDA. “This drug works where others haven’t,” said Mark Genovese, M.D., Stanford University School of Medicine associate professor of medicine (immunology and rheumatology).
CNTO 148 (golimumab): One of the newest TNF blockers, CNTO 148 is administered under the skin once a month. A 2005 double-blind, placebo-controlled study divided 172 patients into four different dosage groups that were compared to a placebo group. The doses were biweekly injections of 100 mg and 50 mg as well as 100 mg or 50 mg every four weeks. It showed effectiveness to some degree in all four groups over 16 weeks, but further investigation is required to better understand the drug’s safety and effectiveness. “The results of this trial demonstrate the potential of CNTO 148 as another therapy for the treatment of rheumatoid arthritis,” said Jonathan Kay, M.D., associate clinical professor of Medicine at Harvard Medical School, and lead author of the study.
DnaJP1: Researchers at the University of California, San Diego, completed phase II trials of the drug, a peptide that comes from a naturally occurring protein, dnaJ. It retrains the body’s Immune system not to attack its own tissues. “It’s a vaccine,” says Keystone, whose patients participated in clinical trials for the drug. Though not on the market, the drug was used in pill form in clinical trials. “It shows that you can alter the immune system with a vaccine. We haven’t found the right vaccine yet but we’re pretty close. We’ve learned that you can re-educate your immune cells not to attack your tissues.”
Rituximab: Marketed under the trade name Rituxan, this drug is FDA-approved for treatment of lymphoma and is being tested in clinical trials for treatment of rheumatoid arthritis. Physicians at the Mayo Clinic and Johns Hopkins, among others, use it to treat RA. “The preliminary data is promising,” says Joan Bathon, M.D. director, the Johns Hopkins Arthritis Center.
If you would like more information, please contact:
Mayo Clinic on Arthritis, by Hunder, Gene G, M.D. (Editor), 2002
Arthritis: A Cleveland Clinic Guide, by Clough, John, M. D., 2006
Arthritis Foundation
http://www.arthritis.org
American College of Rheumatology
http://www.rheumatology.org
National Library of Medicine, National Institutes of Health
http://www.nlm.nih.gov
Johns Hopkins Arthritis Center
http://www.hopkins-arthritis.org
The Cleveland Clinic
http://www.clevelandclinic.org
The Mayo Clinic
http://www.mayoclinic.com
Stanford School of Medicine
http://www.patienteducation.standford.edu