Rheumatoid Arthritis: Podcast Examines New Oral Treatment

Tuesday, May 30, 2017

When it comes to treating rheumatoid arthritis (RA), most clinicians probably have the same initial thought: methotrexate.

But, what do you do when methotrexate isn’t enough?

Dr. James O'Dell, Chief of the Section of Rheumatology at the University of Nebraska Medical Center, takes a look at an emerging therapeutic option — baricitinib — in the latest clinical podcast from the UpToDate Talk series.

The drug baricitinib, which is undergoing regulatory review in the U.S. for treatment of RA, shows potential, not only as a combination therapy with methotrexate, but possibly as a monotherapy.

Why Baricitinib?

Dr. O’Dell bases his discussion on a recent New England Journal of Medicine study that examined baricitinib use in RA patients for whom conventional disease-modifying anti-rheumatic drugs (DMARDs), like methotrexate, had failed.

While conventional DMARD therapy helps many patients with RA, 30 to 50 percent have a suboptimal response, O’Dell explained. These patients then need additional biologic or synthetic treatments to control their RA.

Baricitinib is currently in front of the FDA, hoping to become the second janus kinase inhibitor, or JAK inhibitor, approved to treat RA. O’Dell notes that there are early signs that it may have a different profile of benefits and toxicities than the other approved JAK inhibitor, meaning each drug could develop its own “niche” of patients more likely to respond positively.

In the New England Journal of Medicine study, patients who still had active RA despite methotrexate treatment were treated with either baricitinib, adalimumab (a TNF-alpha inhibitor), or placebo. Both baricitinib and adalimumab proved to be more effective than placebo, as one might expect. What was notable, O’Dell said, was that the ACR20 criteria from the American College of Rheumatology mdash; which looks for 20% improvement in variety of factors — was achieved by more patients on baricitinib than adalimumab. While the difference in response rates for baricitinb (70 percent) and adalimumab (61 percent) were only marginally different and not likely of clinical importance, statistically baricitinib was slightly more effective.

While more research is needed, O’Dell said that a separate study did not find a significant difference for using baricitinib alone versus using it in combination with methotrexate.

“The paradigm has been to add drugs to methotrexate,” he said. This emerging research could “shift the paradigm” with suggestions baricitinib could be used as a monotherapy.

O’Dell noted that there were nine biologics (a tenth has been approved since the podcast) and soon potentially 11 synthetics to choose from and combine to treat RA. Predicting which of these numerous combination options will work best for individual patients is still a matter of clinical judgment, he said, but it is hoped that future research will help clinicians select the best treatment for each individual treatment.

In addition to this discussion of treatment for rheumatoid arthritis, the other segment of the podcast features Dr. Christopher Fanta of Harvard Medical School focusing on the topic of diagnosis and misdiagnosis of asthma.

Listen to the full UpToDate Talk podcast.

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