When RA Treatments Fail To Work – More Common Than One Might Think

There are a variety of medication treatments that rheumatologists and patients use to slow down the destructive processes of rheumatoid arthritis. Over the past 10-15 years there have been an explosion of biological treatments that have had a dramatic impact on the well being of RA patients helping many to achieve a decrease in symptoms with some even reaching remission. The television advertisements for biological medicines for RA show happy and physically active people as a way to demonstrate that their medications work.

The predefined target for clinical remission of RA is from the recently revised American College of Rheumatology (ACR) criteria which are used for research purposes and clinical trials for new drug development.1 According to these criteria, in order to be technically in remission, a patient must satisfy all of the following:

  1. Tender joint count – equal or less than 1
  2. Swollen joint count – equal or less than1
  3. C-reactive protein – equal or less than 1 mg/dl
  4. patient global assessment - equal or less than 1 (on a 0–10 scale) 

These are stringent criteria. The reality is that many RA patients don’t ever reach clinical remission, medications stop working for one reason or another, or side effects are not well tolerated. Researchers are beginning to realize these issues as noted in a review of the literature on biological medications. The authors stated,

“During the last decade we have experienced exciting developments regarding the approval of new treatment options but few patients are reaching sustained remission and refractory patients continue to be a problem. Thus, it is critical to understand how clinicians can decrease the risk of refractoriness by closely monitoring disease activity, using well defined and accepted composite measures, and by early and optimized use of DMARDs, including biologics.” 2

These issues were reiterated in another recent review of the literature,

“However, about 20% to 40% of patients treated with a TNF inhibitor fail to achieve a 20% improvement in American College of Rheumatology criteria, and more lose response over time (secondary failure or acquired therapeutic resistance) or experience adverse events following treatment with a TNF inhibitor.” 1

In spite of the huge, positive impact modern biological treatments have had on RA and other autoimmune diseases, there must be public acknowledgement that up to 40% of patients will not receive enough benefit from these drugs or will need to stop using them due to side effects. Patients, doctors, and researchers need to be aware of the limitations of biologicals. If a treatment doesn’t work or stops working over time, the patient needs to advocate with their doctor for trying a new treatment. Rheumatologists should be willing to try different combinations of drugs in order to provide the best possible outcomes for their patients. Diagnostic criteria for RA including the number of impacted joints, various blood markers, levels of fatigue, and side effects should all play into the decision making process. Researchers, drug companies, and government agencies need to continue to pursue and fund new, more effective treatments and ultimately, a cure for autoimmune diseases like RA so that all patients can experience life to the fullest.

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