Rheumatoid arthritis (RA) can be defined as a chronic autoimmune systemic inflammatory condition characterized by symmetrical polyarthritis. Typically, patients present with pain, stiffness and warmth of the affected joints. The condition can result in extra-articular features, adding to disability, and may eventually lead to premature death, especially if not treated early and appropriately.1,2 Over the past 20 years, the drugs available for treating RA have increased drastically, leading to revised pharmacotherapy strategies. As Bijlsma points out in an article published in 2010, the main changes in RA management were due to new drugs, namely biologics. In turn, these drugs led to improved treatment strategies and a joint European League Against Rheumatism (EULAR)–American College of Rheumatology (ACR) work group, which devised the “treat to target” concept.3-5 The biologic era led to the availability of biosimilars, which are affecting the pharmacoeconomic aspect of the financial expenses of many national health services.6-8
Revolutionized Treatment Strategies
Pharmacological therapy for RA aims to control not only the symptoms of inflammation characteristic of RA but, more importantly, disease progression and remission, if possible. In fact, this is the underlying stem of treat to target. The traditional pyramidal approach that was the mainstay treatment strategy until the late 1990s was based on initiating analgesics and anti-inflammatory agents as first-line drugs.9 If symptoms of RA remained uncontrolled or if there was radiological evidence of progression of the disease, disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, sulfasalazine, sodium aurothiomalate hydroxychloroquine, penicillamine and azathioprine, would be prescribed as second-line drugs. Combination therapies of DMARDs were used in case of continued disease progression and corticosteroids were considered third-line agents.10
The treatment strategy was to hold back the DMARDs, which at the time were considered too toxic for routine use, until disease progression dictated a move up the pyramid. Increased awareness that the progression of RA results in overall decreased quality of life in patients and increased financial burden on the health services led to an inverted pyramidal approach. Traditional DMARDs, such as methotrexate, have become first-line agents and, in accordance with American and European established recommendations, patients with RA are to be prescribed DMARDs within three months of diagnosis.4,11 Analgesics and steroids are used when necessary to control pain and achieve pain-free lifestyles, especially when the effect of the DMARD has not yet kicked in or there is need for an escalation of therapy.
Biologic Drugs & Biosimilars: Implications of Safety & Financial Constraints
Studies into the cellular level of the pathogenesis of the inflammatory process of RA have highlighted the implications of pro-inflammatory markers, such as tumor necrosis factor (TNF) alpha, interleukin (IL) 6 and IL-1.12 The identification of such inflammatory markers has led to the development and subsequent launch of biologic drugs targeting specific pro-inflammatory markers implicated in the inflammatory cascade process.13-16 Over the past decade or so, the place of biologics within pharmacotherapy in the management of RA has been proved through clinical trials, several postmarketing studies and literature reviews.17-19 To this effect, both EULAR and the ACR advocate the use of biologic DMARDs in patients with RA who fail to respond to traditional DMARDs.4,20