I am often asked what treatment or combination of treatments should be used in rheumatoid arthritis. The honest answer is that there is, for now, no best treatment.
The best treatment is the treatment that allows the rheumatoid arthritis patient to feel back to normal once again-or at least as close to back to normal as the treatment allows.
The trouble is that we are not likely anytime soon to see head to head studies of the biologic agents, such as Enbrel versus Remicade, or Humira versus Rituxan. The drug companies might be a little hesitant to fund a study which could prove their drug inferior to that of a competitor.
What we do know is that the development of biological therapies for rheumatoid arthritis has had a hugely positive impact on the lives of rheumatoid arthritis patients. As with all therapies for rheumatoid arthritis, biologic agents have their side effects. We have all seen the news and heard the debates as to whether the biologic agents truly increase the risk of cancer or infection. But we should also all be reminded that the biologic agents appear to improve cardiovascular condition and lower the general death rate; and this reality has, in my mind, more than offset the risks of side effects.
All three tumor necrosis factor (TNF) inhibiting biologics (Enbrel, Remicade and Humira) have been shown to have significant benefits in rheumatoid arthritis. And Enbrel and Humira are more effective in combination with methrotrexate compared to Enbrel and Humira used without methotrexate.
For those patients who do not respond adequately to the TNF inhibiting drugs, there is Rituxan, which attacks the B-cells involved with causing much of the inflammation in rheumatoid arthritis. Rituxan is beneficial with or without methotrexate.
Orencia is also available for those patients who are not helped by the TNF inhibiting drugs. This drug is approved by the FDA for those rheumatoid arthritis patients who don't find relief from either methotrexate or TNF inhibiting drugs.
Regarding safety, it does appear that upper respiratory infections are increased with TNF inhibitor treatment. An analysis of the clinical studies performed for Humira and Remicade found that there was an increased risk of serious infections compared to patients not taking Humira or Remicade. As one might expect, the longer a patient has had rheumatoid arthritis, the greater the risk for serious infection. Likewise, the greater the use of "steroids" such as Prednisone and the use of certain other rheumatoid arthritis drugs can increase the risk of serious infection.
The other safety concern we all have regards the possible increased risk for cancer associated with the treatment of rheumatoid arthritis. There was originally a fear that lymphoma was increased in those patients taking TNF inhibiting drugs; but studies have since shown no increased risk of lymphoma compared to patients taking methotrexate. There does, however, appear to be an increased risk of nonmelanoma skin cancers in patients taking TNF inhibiting drugs. The question as to whether the biologic agents put a rheumatoid arthritis patient who had cancer in the past at risk for a second cancer has not yet been fully answered.
Rituxan has been associated with a serious infection risk similar to that of the other biologics. Likewise, Orencia has been associated with an increased rate of upper respiratory infections, similar to that seen with the TNF inhibiting drugs.
So, it would appear that the benefit of the biologic agents outweigh the risks in otherwise healthy rheumatoid arthritis patients.
But the decision becomes a little more difficult when dealing with those more at risk for serious side effects, such as the elderly, diabetics, chronic lung disease patients, and those on chronic prednisone. If the rheumatoid arthritis is particularly aggressive in these patients, then the benefits of biologic therapy probably outweigh the risks.
Every patient involves a thoughtful and individual decision as to the best treatment in rheumatoid arthritis. Research and the fruits of that research, in the form of more drugs and more knowledge about those drugs, make that decision all the more easy.