Madelaine Feldman, MD: New Directions in Rheumatology

The future of rheumatology is teeming with exciting frontiers, including ongoing trials of JAK inhibitors, growing interest in genetics and epigenetics, and talk about personalized medicine in the area of rheumatology.

“I think everyone's looking for that one test that will tell us what's going to happen with this patient and what's the best drug to use. And I think that's in our future—we'll be able to do that one day,” said Madelaine A. Feldman, MD, FACR, in an interview with MD Magazine®.

Feldman is President of the Coalition of State Rheumatology Organizations, Chair of Alliance for Safe Biologic Medicines, and on the Board of Directors for Rheumatology Alliance of Louisiana.

What clinical trials are you keeping an eye on in the rheumatology space?

How important are genetics in rheumatology?

What is on the horizon for treatment options in rheumatology?

[Transcript has been edited for clarity.]I think the research in JAK inhibitors, particularly in the use in systemic lupus erythematosus is exciting. We have had very few drugs approved for lupus. We have had one approved in the last few years, but there is a dearth of drugs that we have approved for lupus. The FDA has just recently fast-tracked one JAK inhibitor in the study of lupus and there are other JAK inhibitors that are being looked at in lupus. Utilizing medications that work intracellularly to stop the production of the cytokines is where a lot of the research is going. Does dosing make a difference? Do the varying JAK combinations—how is that going to affect various disease states? I think that's been very exciting.You know, patients always ask me: how did I get this? And we always say, well there's probably a genetic susceptibility and then some type of a trigger. I think one of the most exciting things that's coming out—and not just in autoimmune disease—is the entire field of epigenetics. Epigenetics are the genes that can turn off and on the genes that code for the various cytokines, and those can be changed by environment. It’s been shown that everything—from sunlight to infections to even stress—can affect your epi-genes. So, I think in terms of autoimmune disease, when we know sunlight can change the epi-genes and turn them off and on and trigger a DNA methylation that affects t-cells, I think that's probably going be on the foreground of research in genetics and epigenetics.Everyone talks about personalized medicine, and whether it's in oncology with the immunotherapy, and I think in rheumatology—we would like a biomarker to tell us what's the perfect drug to use in this patient. And I think we're getting some headway in that question. There are studies out there trying to decide: would this patient, based on biomarkers, respond to a TNF inhibitor or not or would it be better to use another medication? Can we have a biomarker that will give us an idea of the course? Is this going to be a rapidly progressive rheumatoid patient? We have some things already that tell us if you have a high rheumatoid factor. If you have other non-articular manifestations, perhaps there might be a stronger course, but I think everyone's looking for that one test that will tell us what's going to happen with this patient and what's the best drug to use. And I think that's in our future—we'll be able to do that one day.