Role of Tumor Necrosis Factor-α Inhibitors (TNFi) in RA Treatment

Vibeke Strand, MD, MACR, FACP: The TNF [tumor necrosis factor] inhibitors are a fantastic class of therapy in rheumatoid arthritis [RA], and our first effective biologic therapy. We now have 5 of them, which is a nice thing. However, usually only 1 or 2 are included in the formulary. Although they behave similarly, there may be some reason that a certain patient or physician would like to use one vs another. That may be a bit problematic, but that’s not a major problem. Using the TNF inhibitors is widespread. We have 23 years of data on this class of therapy. They’re quite safe, and they’re easy to use if you don’t mind subQ [subcutaneous] injections either every week or every 2 weeks. Those are great advantages. Where it becomes maybe less of an advantage is say for a patient with early RA who’s a student at university, or even at school. They may not necessarily want to be burdened with having to give themselves injections, and having to find a place to refrigerate the medication, and take care of it and all of that. That is a burden for some people. Also, there are a lot of patients who may be business people or travel extensively. It’s no fun to travel with these subcutaneous injections. They have to be kept cold, so you have to have a special way of taking them, and all the issues about needles, everything else and TSA [Transportation Security Administration] screening.

We’ve seen more or less that it’s 30% to 40% of patients who respond to a TNF. If they don’t respond at all to the first TNF, it’s certainly worth trying a second TNF. But in general, if they’ve failed 1 TNF, we think you do better by switching class. That doesn’t give us much of a choice of the 5 different TNF inhibitors when we want to use them. How many fail after they’ve been taking it? We have patients who’ve been taking TNF inhibitors for 10 years and more, and do really well. But at some point, they may fail the therapy, and then we have to switch. It’s hard to predict how well anyone will respond to a TNF inhibitor, or for how long.

There are a lot of long-term consequences of staying on partially effective RA treatment. Unfortunately, as we look across data and patient series and registry data, we see that a large majority of patients with RA are on only partially effective RA treatment. Now part of that was that we didn’t have as many choices in therapy, but that’s no longer true. What’s problematic is that people don’t follow patients as closely or as stringently for response. Yes, there are the ACR [American College of Rheumatology] and EULAR [European League Against Rheumatism] guidelines, but I don’t know how many practicing clinical rheumatologists are paying attention to definitions of remission. And thinking that when somebody is in low disease activity, that’s sufficient. That’s where we get the disadvantages and the challenges of partially effective RA treatment.

Of course, what happens is that the disease progresses, and when the disease progresses, we get more structural damage. We get more loss of physical function, and patients have worsened health-related quality of life, physically, mentally, emotionally, and very much socially. That means also that they may have difficulty working, and they may also have issues with being socially active, doing things with their family and friends. It’s unfortunate because we should be able to get most patients into at least low disease activity, and preferably even remission. I don’t think we believe there is such a thing as drug-free remission, but there is such a thing as remission. And many patients who have been treated more recently, having been diagnosed more recently, are more likely to go into remission.

Transcript edited for clarity