Patient Created Takeways from EULAR 2022

EULAR 2022, Public Debrief (Part One of Two)

In this first debrief, the team focuses strongly on Personalized Therapy/Medicine, which we define as therapeutic options that are not related to pharmacologic drugs.

Watch the debrief or read the overview below!

Over the past several years at both EULAR and the American College of Rheumatology (ACR) annual rheumatology conferences, we’ve seen a spike in research that focuses on remission and lasting remission. This is a result of over a decade of research that has proven treating to a target, or “Treat to Target/T2T '' early in a patient’s disease journey leads to better quality of life.   (Watch/listen to Tiffany explain the history of treatments, from a pyramid approach in the early 2000’s to targeted approaches in the 2010’s to biologics first/aggressive trials, in the Public EULAR 2022 Debrief). More recently, researchers have built on this theory, conducting research testing a more aggressive approach, called “Step Down Therapy” (See photo), which starts biologic use first*. By using treatments, like biologics, first and early disease onset, data is showing some patients are achieving drug-free remission - which means some can get to a point where treatments may no longer be necessary. In this study on tapering patients with rheumatoid arthritis, all patients who achieved remission with biologics plus methotrexate therapy were then divided into three groups (biologics + methotrexate, methotrexate only, placebo/no treatment). Those continuing combination therapy, even at a reduced dose, resulted in better disease control than switching to methotrexate alone or placebo, but no significant difference was observed in radiographic progression in any of the groups. Some of the patients on no therapy (placebo) did still achieve continued remission, but only around 20% compared to 44% on the combination therapy. 

In the debate, the issue of baseline (where a patient starts in their disease - mild vs severe), comorbidities, lifestyle, and other factors have to be considered to determine who realistically can be tapered off medications and have the best chances of continuing remission. Another factor to consider is, while not common, some patients only have mild disease and, therefore, it’s entirely possible they could achieve significantly improved quality of life without ever trying drugs. 

Our patient panelists then discussed the importance of treating early and the time (sometimes years) it takes to find the right medication - which then decreases the chance of remission. But they also point out that with precision medicine on the horizon, there IS hope for those of us who did not get treated early, as it’s possible new research can match us to better therapies for our individual needs and, in turn, improve our quality of life significantly!

It was mentioned about other prevention studies, that take patients with genetic predisposition to developing RA (family history, certain blood markers and who have known environmental triggers, like those who smoke) and treat them with biologics prior to any onset, addressing the question, “Can we prevent RA?” Currently they could not prove it’s possible, as many of the patients still developed RA, yet it is believed onset was delayed. AiArthritis does not believe these patients were followed over time to assess if they were able, in time, to achieve drug free remission given they were treated early and aggressively…but we’d love to know!

NOT COVERED in our debrief, but new information! From our friend and rheumatology researcher, Auralie Najm, on tapering off of medications for patients with psoriatic arthritis and axial spondyloarthritis who are in clinical remission. Check out her video report!

*The researchers do note that while the data shows the best chances for potential remission (without use of drugs anymore) did occur in people treated early and with more aggressive drugs, they understand unless guidelines would change - or unless a patient presents with very severe disease involvement near onset - it is unlikely at this time to treat this way due to healthcare system/insurance/government preferred drug plans.

How is this related to the work we do at AiArthritis?

Not Another Pill

Presented by Pernille Friis Rønne, Jo Nijs, Christine Stamatos, & Axel Finckh

Chronic pain is a complex issue that requires attention not only to the physical but to the psychological and social issues it causes, too. It also can be exhausting trying to manage self care, so integrative approaches - like lifestyle changes, coping strategies, and building support systems between family and doctors - needs to be incorporated into personalized pain management.

For many years standard treatments involved pharmacologic drug management, but more recently focus has been on research into treating pain with non-pharmacologic options. In the new version of the ‘master codebook’ (ICD-11), Chronic Pain will have its own code, which means it can be treated as its own condition and prescribed therapies - potentially NON-pharma options - to manage it!  Additionally, doctors need to consider “Pain Anamnesis”, or the specific details and causes of pain as explained by the patient, such as debut (when it started), localization (where it’s felt), intensity (how much it hurts), type of pain (why does it hurt). Also, patients beliefs can strongly impact their physical and mental health (i.e. “I’m telling you, there is pain even if you don’t see it!”), so a support system - including being believed by your doctor - is an important step towards managing pain.

Overall, the “gold standard” for addressing pain is to combine biology, psychology, and social factors. An example of this combination - chronic stress activates what are called glial cells (in the central nervous system), increasing adrenaline and cortisol which, over time, increases inflammation (pain). So interestingly, the suggestion is to use a targeted approach (body, mind) since all of these factors of a person's life contribute to chronic pain. 

How is this related to the work we do at AiArthritis?

Historically, the word placebo has been used mostly in clinical trials. When new therapies are tested some of the people in the trial are on the drug, but others are given something (same method, like an injection) but it’s not the drug (could be saltwater). Those on the placebo often will report feeling better, even though they actually have received no medication. This is called a placebo effect. Nocebo is the opposite - this is when you do receive a treatment but before you do you convince yourself it’s not going to work and, thus, it does not. This phenomenon is being studied now as a potential non-pharmacologic way to manage pain. 

Two studies were discussed. The first was a pain study where patients were told, “You are getting a strong pain medication.” Within hours, the patients reported feeling better. However, they never received any medication, but rather saline water. Another study tested patient response to biosimilars, or a newer class of drugs that are similar to the original drug but have slight differences in the non-active ingredients due to manufacturing processes. The patients who were educated on safety and efficacy studies of biosimilars, and who were able to make a choice about switching to them with their doctor, responded more positively to the drug (i.e. “it’s working!”). Whereas those not educated and forced to switch to biosimilars largely reported they were not working as well. 

The concept of mindfulness and how we can use it to influence outcomes is growing. This includes both personal support as well as understanding the chemical changes in the brain that are affected by our perceptions, negatively (associated with the nocebo effect) or positively (associated with the placebo effect). Understanding how the brain is associated with the impact on our immune responses is being explored in regards to the potential to use this phenomenon to minimize medication. While there are many ways outside influences can impact our perceptions - positively or negatively - it is largely thought that the easiest and perhaps most powerful influence can happen when there is a strong patient-doctor relationship. #lovemyrheumy

How is this related to the work we do at AiArthritis?