Several trials have explored interventions to potentially delay or prevent the progression to clinically apparent rheumatoid arthritis (RA) in high-risk groups, but despite some encouraging trends, none had previously met their primary end points. Two new successful trials in abatacept, APIPPRA and ARIAA, are the first to convincingly demonstrate the potential of this preventive approach, but more research is needed.1,2
Prevention in Rheumatology
Historically, management of RA and other inflammatory diseases in rheumatology has focused on secondary prevention (e.g., preventing severe joint erosion) in patients already presenting with clinically apparent, full-blown disease. The diagnosis of RA is a clinical one, but most diagnosed patients also meet the 2010 EULAR/ACR classification criteria, including synovitis of one or more joints, usually evaluated via swollen joints on clinical exam.3 Researchers have begun exploring early interventions in some high-risk patients who don’t fully qualify for a diagnosis of RA.
Dr. Holers
V. Michael Holers, MD, the Smyth Professor of Rheumatology at the University of Colorado School of Medicine, Aurora, shares an analogy between RA and the treatment of cardiovascular disease, which formerly included stroke and heart attack management with few preventive interventions: “We are trying to identify a kind of statin or blood pressure-lowering analog in the at-risk population [for RA] that would stop patients from developing the equivalent of a heart attack—joint inflammation and synovitis.”
The rheumatology community has historically embraced the dictum, “Don’t treat a lab test,” and some
Dr. Deane
physicians have expressed skepticism and safety concerns about potential prevention trials, partly because of potential differences in the risk/benefit ratio in this population, says Kevin Deane, MD, PhD, a professor of medicine in the Division of Rheumatology, University of Colorado. Dr. Deane holds the William P. Arend endowed chair in rheumatology research.
Jeffrey A. Sparks, MD, MMSc, an associate professor of medicine at Harvard Medical School and a rheumatologist at Brigham and Women’s Hospital, Boston, points out that the field has already significantly moved toward treating clinically diagnosed RA earlier and more aggressively, which has greatly benefited patient outcomes. “This approach is trying to turn back the clock even more,” he says.
Dr. Sparks
High-Risk/Pre-RA Populations Defined
A complex variety of factors ultimately leads to the development of clinically apparent RA. Some individuals possess genes that place them at higher risk. These may interact with environmental and other factors, such as obesity, smoking, periodontitis, viral infections or hormones, to increase the risk of clinically apparent RA.4
