Arthur Kavanaugh, MD: Hot Topics in Rheumatoid Arthritis and Psoriatic Arthritis

Rheumatology Network interviewed Arthur Kavanaugh, MD, to discuss his recent Congress of Clinical Rheumatology (CCR) East presentations “The Immunopathogenesis of Psoriatic Arthritis and Immunologically Targeted Therapy” and “Hot Topics in Rheumatoid Arthritis.” Kavanaugh is Professor of Medicine and Director of the Center for Innovative Therapy at UC San Diego.

Rheumatology Network: What are some of the hot topics in rheumatoid arthritis that you discussed at the CCR conference?

Arthur Kavanaugh, MD: There are so many hot topics, but I really focused on the early disease and treatment of early diseases, even including pre-diagnosis of rheumatoid arthritis, and reviewed some of the data for that. I talked a little bit about the newer therapies and newer information on some of the older therapies, including discussing corticosteroids and touching on the optimization for non-steroidal anti-inflammatory drugs. I talked a little bit about the treatment paradigms and need for personalized medicine, which we don't have because we didn't really know which medicine to use and in which order for any individual patient, which is a little bit disappointing, but something that there's been a lot of research looking at. And finally, a lot of discussion about the safety and recent data with the ORAL surveillance study and putting the information from that in clinical context for the practicing rheumatologist.

RN: What are some of the newer therapies in rheumatoid arthritis treatment that you discussed?

AK: The newer ones are the JAK inhibitors. They're the latest to enter the file of therapies that we have available to us for rheumatoid arthritis. We now have tofacitinib, which we've had for a while, and baricitinib, which we’ve have for some years, and upadacitinib is the most recent edition.

RN: What are some of the key takeaways for rheumatologists?

AK: It’s still interesting treating early rheumatoid arthritis or even pre-rheumatoid arthritis, but it's challenging because not all the patients meet the suspicion. They have clinically suspected arthralgia, but not all will develop rheumatoid arthritis. That raises issues about the how best to approach a treatment, including from an ethical standpoint, because we're trying not to over-treat patients.

Another take home point is that there is still an unmet need to figure out which therapy is going to be best for which patient both in terms of effectiveness and also in safety and tolerability. And finally, safety issues. Initially, they’re kind of scary and certainly safeties are important. But it's also important to be able to put it into context so that we can have discussions with our patients about the relative magnitude of the risk and the characteristics that may make people more or less likely to suffer some of the adverse events that we're talking about.

RN: What are some of the challenges facing rheumatologists today?

AK: There are not enough rheumatologists. We have a manpower issue. The prevalence of rheumatic diseases is increasing and we don't have enough fellows, which means we don't have enough young rheumatologists to even replace those who are going to leave the profession by retiring. While it's great to be busy, it's perhaps not so great to not have enough rheumatologists available.

RN: What are the key takeaways from your immunopathogenesis of psoriatic arthritis presentation?

AK: There is more understanding of the different components of the dysregulated immune system and the inflammatory response that seems very relevant in psoriatic arthritis. We've learned more from basic outcomes research in terms of imaging and biomarkers. We've also learned a lot from the results of studies of highly targeted therapies that have given us answers about which domains of psoriatic arthritis may respond as to what specific mechanisms of action. Domains such as skin psoriasis, nail psoriasis, enthesitis, dactylitis, as well as the affiliated conditions like anterior uveitis and also inflammatory bowel disease.

RN: How can this targeted therapy treatment method help both patients and rheumatologists?

AK: Patients want to feel better and they want to feel better across all aspects of their condition. The rheumatologist wants to help them get there and they want to find the therapy that works best for them and is the best for them.