Arthritis Drugs & New Medications-2001 Meeting (cont.)
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 rheumatoid arthritis 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 the methotrexate/Remicade combination in the treatment of rheumatoid arthritis.
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 rheumatoid arthritis 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 rheumatoid arthritis 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 rheumatoid arthritis 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 seems 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 be 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 of them develop it. In fact, I have used Remicade in a number of patients whose condition was originally lupus, but transitioned into classical rheumatoid arthritis without lupus features. None of those patients again developed lupus symptoms and their rheumatoid arthritis 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 being 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.
Remicade was reported as effective for treating psoriatic arthritis and ankylosing spondylitis. For those with psoriasis, Remicade not only helped the arthritis, but also helped to clear the psoriasis, often dramatically. A number of papers not only documented the effectiveness and safety of Remicade, but also showed how it gets prompt results and improved the quality of life for these patients.
Dr. Shiel's Perspective: This is a welcome addition to treatment options that have been sorely lacking for these diseases. (I have actually been treating patients with these diseases very effectively with Remicade for some time now based on preliminary data reported at previous meetings.)
Remicade was found to be effective in much higher than the recommended doses.
Dr. Shiel's Perspective: This is similar to findings in patients with rheumatoid arthritis. That is, many times we must increase the doses above the starting doses to obtain the best results.
Remicade was also reported as effective in treating psoriasis and psoriatic arthritis in patients who had previously failed methotrexate or Enbrel.
Dr. Shiel's Perspective: This is consistent with recent reports of the effectiveness of Remicade in treating rheumatoid arthritis.
Remicade was shown to be extremely beneficial in the treatment of plaque-type psoriasis.
Dr. Shiel's Perspective: This was a fine study of 33 patients that documents not only the clinical benefit of Remicade alone in the treatment of this common form of psoriasis, but also its rapid onset of response of the inflamed skin to the drug.
Remicade was reported in this meeting as being effective for treating juvenile rheumatoid arthritis, thereby resulting in a significant and prompt reduction in disease activity and improved quality of life. Another paper presented data demonstrating that doses of Remicade that are higher than currently recommended doses could be effective and necessary in juvenile rheumatoid arthritis.