Rheumatoid Arthritis - 2001 National Meeting (cont.)

Dr. Shiel's Perspective: This does not surprise me, since it is the same situation for adults with RA.

Remicade treatment allowed for the reduction in the use of simultaneous arthritis medications over time in 40% of patients. In fact, in many instances, patients were able to fully withdraw from other medications to the use of Remicade alone. This included tapering completely off of steroids (such as prednisone) and methotrexate.

Dr. Shiel's Perspective: I have been lowering doses of methotrexate and weaning off of steroids in my patients that have stable disease.

Remicade was reported as safe in 2 patients with RA who also had chronic hepatitis C.

Dr. Shiel's Perspective: I have treated patients with both conditions, but not yet with Remicade. This is may be a reasonable option for certain patients.

Remicade is frequently given together with weekly methotrexate, since this has previously been shown to be helpful in preventing immune reactions to the Remicade. Research was presented that demonstrated the safety and effectiveness of Remicade alone. Also, at this meeting, papers were presented that demonstrated the safety and effectiveness of Arava in combination with Remicade as an alternative to methotrexate/Remicade combination in the treatment of RA.

Dr. Shiel's Perspective: I have treated patients with the Arava/Remicade combination successfully after hearing of previous preliminary reports. It is a treatment option for certain patients, such as those who could not tolerate methotrexate.

Both increasing the dose of Remicade and decreasing the interval between infusions were shown to be effective methods in capturing control of RA in several studies.

Dr. Shiel's Perspective: This is something I have already been doing in practice for the past 2 years. While it does not always work for those resistant cases, it can be very effective.

If Remicade is stopped, it was reported to result in a flare of the RA in an average of 4 months in 2/3 of patients.

Dr. Shiel's Perspective: This makes complete sense since Remicade is basically a powerful antiinflammation drug that only works when it is blocking the inflammation promoting protein, tumor necrosis factor (TNF). When it is out of the system, eventually the inflammation of the RA should return--(and does, on the average of about 4 months, as was shown at this meeting).

Three papers reported reactions to the Remicade infusions at rates of 4.3%, 5.5%, and 5.7%. They were generally reported between the second and fifth infusions of Remicade.

Dr. Shiel's Perspective: This is in line with previous reports and seems to be the most significant of the reactions to Remicade. These can often be prevented or minimized by pretreatment with antihistamine drugs and/or cortisone injections. Aspirin use also seem to have a preventative effect against infusion reactions, but the researchers I spoke with were really not certain as to why this happened.

Patients taking Remicade developed DNA antibodies (known to be associated with lupus) in 16% of patients. These antibodies were not felt to significant as they were not related to the development of lupus disease.

Dr. Shiel's Perspective: This has been my experience. I have been monitoring my patients closely for signs of lupus, but have never had any develop it. In fact, I have used Remicade in a number of patients who's conditions were originally lupus, but who transitioned into classical RA without lupus features. None of those patients again developed lupus symptoms and their RA was controlled.

Remicade also was shown to be effective in patients who had previously tried and failed Enbrel. One study reported Remicade and Enbrel as equally effective.

Dr. Shiel's Perspective: I have had some successes here as well. I have also had successes using Enbrel in patients who had failed Remicade. I agree that both drugs are similarly effective.

Enbrel (etanercept)

Enbrel is an injectable anti-tumor necrosis factor for treating rheumatoid arthritis. Tumor necrosis factor (TNF) is a protein that the body produces during the inflammatory response, the body's reaction to injury. TNF promotes the inflammation and its associated fever and signs (pain, tenderness, and swelling) in several inflammatory conditions, including rheumatoid arthritis. Enbrel is a synthetic (man-made) protein that binds to TNF. Enbrel thereby acts like a sponge to remove most of the TNF molecules from the joints and blood. This prevents TNF from promoting inflammation and the fever, pain, tenderness, and swelling of joints in patients with RA.

Enbrel plus methotrexate was reported at this meeting to be more effective than Enbrel alone.

Dr. Shiel's Perspective: This may be true, to a degree, for both Enbrel and Remicade, but I use them individually or with methotrexate or other drugs on a case by case basis.

The long-term safety of Enbrel in more than 2,600 patients over 5 years was reported. There was no cumulative toxicity with extended use and the clinical response was sustained for up to 5 years of the study.

Dr. Shiel's Perspective: These long-term statistics are very helpful for doctors who are assessing the value of this relatively new treatment for rheumatoid arthritis.