COMMENTARY

Is Rheumatology in a Rut?

Nathan Wei, MD

Disclosures

April 05, 2017

Is the revolution over?

When it comes to arthritis treatments, how far have we come? Where do things stand now?

If you believe the bulletins put out by the American College of Rheumatology, we have pretty much conquered all of the well-known rheumatic conditions and are now simply investigating the really uncommon ones, such as Erdheim-Chester disease or systemic capillary leak syndrome (The Rheumatologist, February 2017 and December 2016).

Give me a break!

I do not believe that I have ever seen these conditions in my lifetime. If I did, I missed them.

In 1998, the US Food and Drug Administration approved the first biologic therapy for rheumatoid arthritis (RA). Since then, a plethora of biologic therapies with different mechanisms of action have been approved and used with great results—not only in RA but also in psoriatic arthritis and various other spondyloarthropathies. When I first started practicing medicine, all we had for patients with RA were poisons: gold, penicillamine, cyclophosphamide, and azathioprine. We have come a long way with this disease.

Unfortunately, we are now hitting the wall. The wall occurs when "me too" drugs start popping up. You know what I am talking about: drugs that basically do the same thing as already approved medications, but have "different targets." We have five tumor necrosis factor inhibitors and will soon have at least three interleukin-6 inhibitors.

There are more JAK inhibitors than we can shake a stick at. This proliferation always happens; I remember the same thing occurring with nonsteroidal anti-inflammatory drugs back in the day.

Even for patients who do not need biologics, the picture is not as rosy as it initially appears; not a whole lot has occurred with gout, for example. I do not believe that lesurinad is a major advancement over existing therapies (despite the hype), because it is contraindicated for patients with compromised renal function. And how many patients with severe gout have perfectly functioning kidneys?

Osteoarthritis, you ask? Fuhgedaboutit! There have been no significant breakthroughs in the last few decades, which is shocking, given that OA is the most common type of arthritis. And it is the one with the most potential to treat.

The typical image of a rheumatologist is someone who diagnoses a rare condition, increases or decreases doses of medicine, and orders a lot of lab tests. As an interventional rheumatologist, I find that unacceptable. If the aim is to help patients with rheumatic conditions, we are ceding that to orthopedic surgeons, physical medicine doctors, and pain management physicians.

When I think about the early rheumatologists, such as Henri Dorfmann and Thierry Boyer, who helped pioneer arthroscopy, I feel disappointed that our generation of rheumatologists has been content to cogitate and contemplate their navels. It's wrong! There is more to treating patients with rheumatic disorders than working in a lab, writing papers, increasing and decreasing medicine doses, making abstruse diagnoses, and teaching students about synovial fluid characteristics.

Research into novel therapies for all sorts of rheumatic conditions—which is one of the foci of our work at our center—is one of the ways in which rheumatologists can get out of this rut. We need to continue to innovate so that our patients regain quality, not just quantity, of life.

Sir William Francis Butler said, "The society that separates scholars from its warriors will have its thinking done by cowards and its fighting done by fools."

As a community, rheumatologists need to come together and strive for what's new and what's next. We are the ones who are seeing patients in the clinic; we understand better than lab researchers what our patients need.

I will continue to seek out institutions and organizations who are pioneers in the field to collaborate with. I want to be involved with research that tries to do something different, not reinvents the wheel. I encourage you to do the same.

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