Most people with rheumatoid arthritis (RA) have to try several different drugs before finding one that suppresses their disease. This trial-and-error process can be expensive and often allows the disease to progress and cause damage. And not everyone with RA responds to what’s currently available.
Imagine a future in which you are diagnosed before you feel any symptoms. Treatment would be developed based on your genetic makeup, environment, and lifestyle, as well as scientific evidence of others like you and an understanding of the genetics of the condition itself. You’d immediately start this treatment that might stop your RA before it starts or bring you into remission.
That’s precision medicine.
This is a complex approach, which will require “redefining diagnoses and treatment paradigms based upon ever-increasing data from genetic studies, new laboratory discoveries, social studies of disease, and factors unique to certain groups of people,” said Dr. Robert G. Hylland, fellow of the American College of Rheumatology, and assistant clinical professor at the Michigan State University College of Osteopathic Medicine.
Precision medicine and RA
“Precision medicine is a concept many years from effective implementation. There will be partial successes sooner. In fact, there already are some in the fields of Rheumatology and Oncology,” Dr. Hylland said in an email interview. In both fields, people with the same condition receiving the same treatment may respond differently. This has led to an understanding that the genetics of the disease and the genetic background of the individual influence the outcome of treatment.
“Genetic studies will help define the most effective medications and potential for side effects,” Dr. Hylland explained. This is not currently available, but research is very promising. “Very recent research suggests we may be able to cut out unfavourable genes from specific immune cells and splicing beneficial genes to quiet immune diseases like RA,” he said.
A vision for health
One of the challenges in healthcare is that by the time someone is diagnosed, their condition may have become advanced. Researchers believe that changing the approach to precision medicine has the potential to shift medical care to one of prevention and prediction. That is, predicting if someone is likely to develop a particular condition — diabetes, high blood pressure, RA — and addressing it before it develops.
The concept of precision medicine is an exciting one, but more than a bit complicated to put into clinical practice for a wide variety of conditions, including RA. But we are on our way. Sequencing of the human genome has provided the kind of information that has progressed research by leaps and bounds.
In addition, we now have the capacity to store and use large databases and increasingly the tools to perform complex analysis of biological samples. All of this together is driving the progress that is making precision medicine possible.
“I’m certain that, one day, we will utilize a computer-generated algorithm for diagnosing and treating RA in a manner much more efficient than what we utilized today,” Dr. Hylland said.
To help us get there, All of Us, previously known as the Precision Medicine Initiative, a large research project, will gather data — genetic, biological, lifestyle — from more than one million Americans. The results of this will form the scientific evidence necessary to begin transitioning the concept of precision medicine into clinical settings.
Twenty-five years ago, I attended a talk by Dr. Edward Keystone, a prominent Canadian rheumatologist. He described the treatment of the time as “carpet bombing” the immune system, telling the audience that researchers were looking for highly targeted treatments. Those treatments are biologics. A few years ago, I listened to Dr. Keystone describing the latest research as identifying pre-clinical RA and stopping the disease before it starts.
Cutting-edge research can be oddly discouraging. If you can’t use it now, when you so very much need it, it can seem almost like a fairy tale — something not quite real. But just as biologics became real, so will our ability to stop RA in its tracks. Dr. Hylland described it as the ability to “fulfil the promise of perfection implied in the tenets of precision medicine.” With the advances in rheumatology that happened in just the last few decades, I fully believe that a cure will be found in our lifetime.
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