Rheumatoid Arthritis Treatment Window of Opportunity

Treating patients with rheumatoid arthritis (RA) during the accepted “therapeutic window of opportunity” — such as within 3 months of the onset of symptoms – can benefit patients, according to an editorial published in the Annals of the Rheumatic Diseases.

Karim Raza, BA, BMBCh, FRCP, PhD, and Andrew Filer, PhD, MRCP, of the University of Birmingham in the United Kingdom wrote an editorial discussing the window of therapeutic opportunity and the importance of earlier rather than later treatment. The editorialists commented that determining whether the existence of a time limited window of opportune treatment for RA patients is extremely important, they urged; if such a window does exist, they wrote, future research should be directed at determining the reasons for enhanced responsiveness within this period of time.

The authors first cited 2 studies conducted on large populations that aimed to address the relationship between symptom duration and initial rheumatology assessment and favorable outcomes. Those efficacy points centered around remission without disease modifying anti rheumatic drugs (DMARDs), sustained remission regardless of DMARD use, and low rates of radiological progression. These studies suggested there is a period within about 6 months after symptom onset, potentially even short, in which treatment is optimal.

However, the authors wrote, the implications of studies such as these can be challenging. Many patients today fall outside of the therapeutic window — in Europe in 2009 and 2010, the median delay from symptom onset to patients seeing a rheumatologist across 10 centers was 24 weeks. There are delays on 3 levels, the editorialists say: the patient seeking help in the first place (usually their general practitioner (GP)), delay of the GP referring the patient to a rheumatologist, and delay on the part of the rheumatologist in assessment of the patient.

“Further research is clearly required in this area, as unique pathological processes operating during the earliest stages of clinically apparent synovitis may suggest that therapeutic approaches should be modified according to whether treatment is being administered within the therapeutic window or not,” the authors wrote in their paper.

The writers also offer alternative explanations for this window of opportunity, mentioning that patients are not automatically inside of a therapeutic window of opportunity if symptoms begin. Patients with RA are likely to be treated early if the symptoms appear early, but treated later when symptoms appear later, the authors wrote. RA in the larger joints is treated sooner in general, but smaller joints may pose a greater problem.

“Patients with new onset RA present with a wide range of symptoms besides joint pain and swelling including fatigue and morning stiffness,” the authors concluded. “If a patient was to present with a 9-month history of fatigue and stiffness and a 3 week history of joint pain and swelling would they be inside or outside the therapeutic window?”

Regardless, the authors said, the data is important because it suggests a window of opportunity, even though pinning down the time frame still needs additional work.