Understanding emerging treatment paradigms in rheumatoid arthritis
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REVIEW
Understanding emerging treatment paradigms in rheumatoid arthritis Ferdinand C Breedveld1* and Bernard Combe2
Abstract Treatment strategies for rheumatoid arthritis (RA) will continue to evolve as new drugs are developed, as new data become available, and as our potential to achieve greater and more consistent outcomes becomes more routine. Many patients will find both symptom relief and modest control of their disease with disease-modifying antirheumatic drugs (DMARDs), yet this course of therapy is clearly not effective in all patients. In fact, despite strong evidence that intensive treatment in the early stages of RA can slow or stop disease progression and may prevent disability, many patients continue to be managed in a stepwise manner and are treated with an ongoing monotherapy regimen with DMARDs. There is now a large body of evidence demonstrating the success of treating RA patients with anti-TNF therapy, usually in combination with methotrexate. As a result of the increased use of anti-TNF therapy, treatment paradigms have changed – and our practice is beginning to reflect this change. In the present review, we summarize the salient points of several recently proposed and emerging treatment paradigms with an emphasis on how these strategies may impact future practice.
Introduction To evaluate the success of any treatment paradigm, it is critical to define the optimal treatment goals in rheumatoid arthritis (RA) and to determine how achievement can be measured. Treatment goals
Untreated inflammation leads to tissue damage; and the longer RA is left untreated, the greater the extent of the *Correspondence: [email protected] 1 Department of Rheumatology, Leiden University Medical Center, C1-39, PO Box 9600, 2300 RC Leiden, The Netherlands Full list of author information is available at the end of the article
© 2010 BioMed Central Ltd
© 2011 BioMed Central Ltd
damage [1]. As most joint damage is largely irreversible, persistent damage will inevitably result in greater disability [1]. The treatment goals in RA therefore include [2,3]: prevention or control of joint damage; prevention of disease progression; prevention of loss of joint function; a decrease of symptoms (for example, pain and stiffness), and achievement of remission or low disease activity; improvement in quality of life (QoL) and maintenance of lifestyle; achievement of drug-free remission; and rapid control of underlying inflammation. Diagnosis and treatment of RA early in the disease course provides symptom relief and also prevents longterm structural damage and functional decline [4], with a concomitant improvement in QoL and maintenance of everyday activities of daily living. Considering the accepted concept of early treatment in the disease course, a window of opportunity may exist whereby therapeutic intervention could have a disproportionate impact on outcome, resulting in remission induction and maintenance of response after cessation of treatment [5]. The ultimate goal of treatment is to achieve drug-free remission. Previo
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