Perhaps, therefore, it is time to acknowledge the efficacy of current treatment and to look critically at patients with RA (and other diseases like psoriatic arthritis and ankylosing spondylitis) in whom the need is met. For starters, I would like to see clinical trials that address two salient questions: 1) Among existing disease-modifying antirheumatic drugs, which agents or combinations have the highest chance of inducing sustained remission? and 2) In patients in whom remission can be achieved, what is the optimal duration of therapy and sequencing of drug withdrawal in patients on combinations?
Funding Essential Research
An equally pressing question relates to the funding of these trials. Head-to-head comparisons of existing agents and drug-withdrawal trials are not industry’s cup of tea. Indeed, I think that those at the helm in corporate board rooms look at such trials as cups of hemlock. These studies are essential, however, and they require big dollars. I think that it is time for the National Institutes of Health (NIH) to step up and take the lead in this type of research. I am a patriot and, as an American in Paris during the European League Against Rheumatism (EULAR) meeting there earlier this year, I was disappointed that NIH-sponsored research did not occupy a more prominent place in cutting-edge research on the treatment of RA.
Back in North Carolina, Durham’s Main Street is not the Champs-élysées, but the sky glistens with Carolina blue, the sun glows silver-white, and I need a walk.
A research agenda for the met need in RA would be large in scale and would galvanize investigative interest in concepts such as prevention and cure. Such an agenda could help stimulate academic rheumatology and forge the creation of cooperative research networks of the kind that have been so successful in specialties such as oncology and cardiology.
Although I think that we can improve upon the met need, I would be remiss in not mentioning a truly unmet need: a rational and equitable insurance system for funding treatment even with existing agents. In this country, we have created an adversarial system, driven by cost, in which doctors and insurers struggle over the use of effective therapy. Until America makes headway over this unmet need, RA therapy will likely be suboptimal.
Paris is a luminous place during the day as well as night, and being in a conference center when the sun shines brightly on that glorious place is not good for the soul. I therefore took several breaks during the EULAR meeting and, during one of these interludes, I meandered over to the Arc de Triomphe, which is one crown jewel in Paris’s architectural treasure chest. This iconic structure was commissioned in 1806 after Napoleon’s victory at Austerlitz and honors French war dead, especially those in the Napoleonic wars. A key link in the l’Axe historique, the Arc is at the center of the Place Charles de Gaulle, which I learned in high school as the Place de l’Etoile.
