CORE BLOG POSTS

Marc Cohen, MD

Clinicians’ Hostility

Hearing in rheumatology clinic yesterday that the fellows do not like calculating a Clinical Disease Activity Index (CDAI) on their rheumatoid arthritis (RA) patients, my colleague reminded me that promoting objective measurement in RA has been one of my unsuccessful, ongoing projects for more than a decade. There is still much resistance. Consistently measuring RA disease activity with any objective index and targeting treatments according to the measurement is a concept adopted by the American College of Rheumatology and European League Against Rheumatism.

Marc Cohen, MD

Those Other Niches

The B-cell depleting agent rituximab is very efficient at eliminating most, if not all, circulating peripheral B-cells, probably quickly depleting upwards of 98% of these cells. Obviously, however, this drug is not 98% effective in the treatment of any rheumatologic disease. In fact, how much rituximab to use in rheumatoid arthritis, systemic lupus erythematosus, and ANCA-associated vasculitis remains uncertain, and the protocols used for the treatment of each disease differ. The initial induction treatment dose also appears to be different than the subsequent maintenance dose.

Marc Cohen, MD

Niches?

There have been a number of presentations lately of new drugs with interesting and unique mechanisms of action. Think of ustekinumab and apremilast for psoriatic arthritis, and mavrilimumab and tabalumab for rheumatoid arthritis. These agents appear to be efficacious, but perhaps not as efficacious as some of the drugs currently available. Does this kind of comparison damn these drugs to the pharmaceutical purgatory of “insufficient evidence to warrant further development?” As clinicians, can we afford to believe that only blockbuster new drugs should be brought to the marketplace?

Gregg J. Silverman, MD

Biosimilar Biologic Agents for RA on the Horizon

Biologic agents for the treatment of inflammatory diseases are now well-accepted components of rheumatologists’ armentarium. However, the patent protection for some of the oldest agents is either fast approaching or has already expired in the European market. In fact, the first US Food and Drug Administration (FDA) approvals for the tumor necrosis factor (TNF) blockers, infliximab and etanercept, occurred in 1998.

Marc Cohen, MD

My Back Pages Redux

Looking for something the other day, a reprint of an old article revealed itself. An editorial, it was over-written, emotional, strident, and more than a little obnoxious. Entitled “We Are Better Than Guidelines,” it railed against formalized decision making as an insult to the intelligence and imagination of rheumatologists.

Marc Cohen, MD

Less Is More

Reviewing the abstracts for the upcoming national meeting, it seemed obvious that several had already been presented at the large, international meeting in June. Some had a slight change in the number of patients, a few had a new twist, but most were identical to what had been presented already. Why is this allowed? The abstract reviewers are almost always very qualified rheumatologists with a full command of the available literature, including important abstracts from previous meetings. They should know if the abstracts have been presented previously.

Gregg J. Silverman, MD

RA and “The Road to Wellville”

The 1993 novel by TC Boyle portrayed events in 1907 and 1908 inside a health sanatorium in Battle Creek, Michigan, which was founded by a fictionalized John Harvey Kellogg.1 Following a holistic philosophy that dictated a rigid vegetarian diet and rigorous daily exercises and treatments, Dr. Kellogg supervised a facility that sought to impart a healthier and happier lifestyle. The patients were assured that if they were faithful to the regimen, there would be very positive consequences.

Marc Cohen, MD

Not Open and Shut

The window of opportunity in the treatment of rheumatoid arthritis (RA) is supposed to represent an early phase of the disease, during which treatment is most successful, presumably because the underlying immunopathology is somehow more susceptible. The related possibility is that treatment during this period may alter RA progression, changing the natural history of the disease.

Marc Cohen, MD

Anti-Antibodies Again

Judging from the number of abstracts and articles lately, there is apparently renewed interest in anti-drug antibodies (ADAs), particularly antibodies against the tumor necrosis factor (TNF)-inhibitor products. A smart European rheumatologist commented to me, “The value of measuring ADA in clinical practice is slowly being better elucidated.” Really?

Marc Cohen, MD

Is Any Publicity Good Publicity?

In June of this year, the New England Journal of Medicine (NEJM) published a study by O’Dell et al.1 The study was a 1-year, non-inferiority trial, essentially comparing triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine to methotrexate plus adalimumab in a cohort of rheumatology (RA) patients with a prior inadequate response to methotrexate. The study’s conclusion was that in this group of RA patients, triple therapy was non-inferior to and significantly cheaper than methotrexate plus the tumor necrosis factor (TNF) inhibitor.

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