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American College of Rheumatology Annual Meeting

New therapeutic avenues for inflammatory arthritis

Research into the mechanisms which underpin hard-to-manage arthritis and how it might help to predict responses to existing therapy and develop new therapies was highlighted at a special session of the ACR Annual Meeting.

The role of T cells in RA was discussed by Dr Adam Mor, Assistant Professor of Medicine and Pathology at New York University, US.

T cells from patients with RA do not function well in terms of adhesion, said Dr Mor, whose research has shown that the programmed cell death protein 1 (PD-1) receptor regulates T cell adhesion.

Dr Mor presented data on the biology of the PD-1 receptor, its signalling and function. “This is important, because feeding the cells with the ligand of the receptor could be a good treatment for RA,” he said.

Meanwhile, another potential contributing mechanism to inflammatory arthritis was discussed during a talk by Dr Peter Nigrovic, Associate Professor at Harvard Medical School and Director of the Brigham and Women’s Hospital Centre for Adults with Paediatric Rheumatic Illness, Boston, US.

“Glycosylation of the Fc (fragment crystallisable) portion of IgG (immunoglobulin-G) affects the effector capacity of antibodies, rendering them more or less potent at triggering inflammation,” said Dr Nigrovic.

“We investigated the hypothesis that changes in IgG glycosylation could contribute to inflammation in juvenile idiopathic arthritis.”

The IgG glycans shift “to a rather remarkable extent during normal childhood” and those changes may render antibodies potentially more pro-inflammatory in the context of arthritis, he outlined.

Role of gut in preventing axial spondyloarthritis

Recent research into the pathogenesis of axial spondyloarthritis suggests that the progression of the disease may be preventable.

The role of gut inflammation in spondyloarthritis was discussed in a presentation at the ACR Annual Meeting by Dr Dirk Elewaut, Chair of the Department of Rheumatology, Ghent University Hospital, Belgium.

“So-called ‘microscopic gut inflammation’ seems to be very important in determining the disease severity and outcome, as it represents an important key factor for development of Crohn’s disease as well as for evolution to ankylosing spondylitis,” said Dr Elewaut, who recently became a Principal Investigator at the Inflammation Research Institute, Flanders Institute of Biotechnology, Belgium.

He discussed several new advances in the field, including the link with therapy response, as well as a non-invasive screening strategy to detect microscopic gut inflammation, along with recent data on dysbiosis and spondyloarthritis disease activity.

New therapies are emerging for both spondyloarthritis and inflammatory bowel disease that can make an impact on gut and joint disease, he outlined. “A better understanding of the role of gut inflammation in spondyloarthritis is therefore important for clinicians,” noted Dr Elewaut.

Advances in psoriatic arthritis management

It is an “exciting time” for psoriatic arthritis treatment as new drugs emerge that are specific to this disease, Dr Laura Coates, National Institute for Health Research Clinical Lecturer in Rheumatology, University of Leeds, UK, told the ACR Annual Meeting.

Dr Coates discussed efficacy data on new treatments emerging for psoriatic arthritis, how patients should be selected for disease-modifying antirheumatic drugs (DMARD) therapy and monitoring clinical outcomes.

“A lot of newer drugs focus on the IL-17 pathway, which is a different part of the immune system [than what previous drugs targeted] and which seems to be particularly important for psoriatic arthritis, psoriasis and spondylitis arthritis,” said Dr Coates.

There is a shift towards a ‘treat to target’ (TTT) approach in managing psoriatic arthritis, said Dr Coates. This means that if a patient does not meet a predetermined clinical outcome with one treatment approach, then the rheumatologist changes the treatment.

“TTT results in changing treatment quicker if it is not working and aiming for a very high target of patients doing really well,” she outlined.

Dr Coates discussed the first randomised trial of a TTT approach in TICOPA (effect of tight control of inflammation in early psoriatic arthritis), which she conducted with colleagues.

The European League Against Rheumatism revised its psoriatic arthritis management recommendations to advise in favour of TTT as a result of the findings that emerged from TICOPA.

Expansion of urate-lowering therapy may improve gout care

Urate-lowering therapy, or ULT, is known to be an effective strategy for preventing gout attacks, but studies show that only a small number of those patients with indications for treatment receive ULT.

“Gout is the only curable chronic arthritis, so why is this curable condition just not being cured?” asked Prof Michael Doherty, Professor of Rheumatology, University of Nottingham, UK.

Prof Doherty discussed strategies for expanding the use of ULT and the growing prevalence of gout and its comorbidities.

Gout is the most common type of inflammatory arthritis in the US, where it affects about 4 per cent of the adult population.

“Current guidelines are taking the patient-centred perspective that ULT is at least discussed with patients, even around the time when you first make the diagnosis rather than wait 10 years until they are really bad and their gout is causing them depression,” said Prof Doherty.

He presented results from a proof of concept study showing that when patients receive full information about gout and management options, and are involved in treatment decisions, 100 per cent of patients wish to receive ULT.

The study further found that, after one year, more than nine out of 10 of such patients were adhering well to ULT.

Prof Doherty also presented preliminary data from an ongoing two-year, randomised, controlled trial comparing nurse-led care and standard general practitioner care of gout patients.

The group that received nurse-led care got full, individualised education from nurses about their condition and care, had greater uptake of ULT and better management of pain and other gout symptoms. 

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