COMMENTARY

Rheumatology Trends to Watch in 2015

Kevin Deane, MD

Disclosures

January 12, 2015

In This Article

Effectiveness of New Therapies

The last year or so has seen many important advances in rheumatology, many of which will likely have a growing influence on the field in 2015. Below I've highlighted some of these areas of research, starting with promising therapeutic data.

Date were increasingly positive about the effectiveness of rituximab for the initial treatment as well as maintenance of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis.[1,2]

In seronegative spondyloarthritis (SpA), data emerged about the ability of early use of anti-tumor necrosis factor (anti-TNF) alpha therapy to improve long-term outcomes.[3] There were also advances in the understanding of mechanisms of inflammation (eg, interleukin [IL]-23 and IL-17 pathways), mechanical strain, and bone formation.[4,5] Furthermore, the discovery of some autoantibodies (eg, anti-noggin and anti-sclerostin) in these diseases that were previously thought to be "seronegative" may soon change our understanding about the underlying pathophysiology of these diseases.[6] More controversially, the entity of non-radiographic axial SpA (nr-axial SpA) saw increasing exposure in the literature.[7]

In rheumatoid arthritis (RA), where for years rheumatologists were just trying to gain control of disease, an increasing number of studies found that in some patients, tapering of medications may be possible without substantial loss of disease control.[8,9] Growing data informed us about the safety, efficacy, and potential clinical role of tofacitinib (Xeljanz®).[10] We also gained a deeper understanding of how and when to use corticosteroids most effectively in RA.[11]

In systemic lupus erythematosus (SLE), there was increasing understanding of the long-term benefit of hydroxychloroquine (Plaquenil®)[12] and a refinement of where anti-B-cell therapy might fit in disease management.[13,14] More data are needed, but tacrolimus as part of a multi-drug regimen may help prevent proteinuria in lupus nephritis.[15] Unfortunately, abatacept (Orencia®) did not appear to improve outcomes in patients with renal disease.[16]

The effects of these advances will be important to watch in 2015. In particular, it will be of great interest to see how the data on the effectiveness of rituximab in ANCA-positive vasculitis affect clinical care.

Moreover, it will be of interest to see whether more patients with axial SpA are started on anti-TNF therapy earlier, although we can also expect to see further controversy about the diagnosis and management of "nr-axial SpA." It will also be of interest to see how a potential for tapering medications in RA will affect clinical care. Of importance, will patients whose lives have been changed through use of an anti-TNF agent willingly part with it, even if their disease remains well-controlled in the eyes of a rheumatologist?

Early Diagnosis, Long-term Management, and Treatment Guidelines

Other important areas to watch will be the longer-term impact of the Affordable Care Act on patients with rheumatic disease in terms of early disease diagnosis as well as long-term management. Because we now realize that early recognition and treatment of a variety of rheumatic diseases leads to improved long-term outcomes, hopefully our healthcare system will facilitate such care.

Several new treatment guidelines are anticipated from the American College of Rheumatology in early 2015. These include guidelines for RA, axial spondyloarthropathies, and polymyalgia rheumatica. Hopefully, these guidelines will help lead to uniform improvements in the standards of care in these areas.

In terms of mechanisms of disease, neutrophil extracellular trap (NET) formation was shown to play a role in the pathogenesis of RA.[17] In addition, peptidyl arginine deiminase inhibition appeared to reduce NET-related inflammation and injury in a murine model of SLE.[18] These findings open the door to novel treatment paradigms for both of these rheumatic diseases.

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