Dr. A. Silvia Ross, MD, rheumatologist at Triangle Arthritis and Rheumatology Associates talks about a new treatment for severe rheumatoid arthritis.
Interview conducted by Ivanhoe Broadcast News in May 2022.
What is rheumatoid arthritis?
DR ROSS: Osteoarthritis is a degenerative process. It’s inherited and it’s wear and tear of the joints. Rheumatoid arthritis is what we refer to as an autoimmune disease. For some reason, the immune system has decided that the joints are no longer part of you, and the immune system that should know what’s you, what’s not you, what’s bad for you, and get rid of the what’s bad for you, suddenly decide your joints and other body parts are bad for you. Rheumatoid arthritis is a systemic autoimmune disease in which the immune system is at war. The joints are the primary target, but it can involve many other organs. It can affect the eyes. It can affect the lungs. It can affect the blood vessels. It can be an angry disease.
Does it occur mostly in women?
DR ROSS: It is more frequently found in women, but it is a disease of men and women. It is a disease that has no age. It can start as young as babies and as late as mid-90s.
What are some telltale symptoms? How does someone know that this is starting?
DR ROSS: In most patients, the classic textbook presentation is going to be pain and swelling of the joints, usually both sides of the body, with oftentimes wrist involvement and the proximal joints of the hands. But it can involve elbows, shoulders, knees, hips, ankles, feet, and sometimes it will present in a different joint. Patients typically are going to notice that they wake up in the morning feeling horrible. They’re stiff and they can barely move, and it may take an hour or longer to be able to close their hands or to hold a cup of coffee, and as the day goes on, that may loosen up a little bit and get a little better. That is the early manifestation. Over time, if not recognized and treated, rheumatoid arthritis can cause very severe permanent damage to the joints, causing disability and making patients unable to use their joints.
How is it treated?
DR ROSS: Treatment of rheumatoid arthritis is aiming at trying to get that immune system to behave again. Until the ’90s, we just had a lot of the medications that we now refer to as conventional disease modifier antirheumatic drugs, things like methotrexate, plaquenil hydroxychloroquine, and such. And in the late ’90s, there was a huge revolution in treatment with the development of biologic antirheumatic drugs. So, the biologics are a class of their own. They are not created in a lab with chemicals; they are created biologically by teaching lab cells to produce certain antibodies or mock receptors that will aim at very specific molecules. There are different targets within the immune system. As we learned about rheumatoid, we start to understand which cells are talking to which cells and how they communicate. Nowadays, we also have medications that help block the communication from the surface of the cell to the inside of the cell, so that when one cell sends a message to the next cell saying the joints are bad and we need to be destroying them, if the message doesn’t make it from the surface of that cell to the nucleus so that the proteins can be made, that interrupts the process. The biologics are based on our understanding of what happens in the system during an inflammatory arthritis like rheumatoid. They interrupt or decrease that process by blocking one of those chemical messengers or blocking how the message is sent within the immune system.
How do, and others who are treating the disease, know which drug and which treatment is going to work best for each patient?
DR ROSS: That is the biggest challenge. Since 2000, or so, we have had more and more different biologics, different small molecule medications that have different mechanisms of action. The holy grail of rheumatology has been how the heck do you know which drug is going to work for whom? And the problem with these drugs is that they don’t work overnight. They take a while to work. Some start to work as quickly as one or two weeks, but on average, we need to give it 12 to 16 weeks before we can see what they’re going to do. Over the years, we had to do the guessing game. So, in the early 2000s, we only had one class of drugs that were called the TNF inhibitors. And then, they developed different classes that had different mechanisms of action. What happened was early on, everybody got a TNF inhibitor, and then, that failed. We would try the next class and then the next class, always hoping to find some way to identify who could take this, who could take that? We have had some incredible development recently in that we now have a molecular signature test, which was developed by a company called Scipher. Based on an enormous number of proteins that they have studied and interactions between proteins, they have now been able to identify a test that tells you who is unlikely to respond to a TNF inhibitor. So, what does that mean? It means that if you come in as a patient with bad rheumatoid arthritis and we decide we need to move on to a biologic, we do that blood test. If the blood test says that you are not likely to respond to a TNF inhibitor, I just saved you 16 weeks of treatment that doesn’t work. I just saved your insurance company thousands of dollars on the treatment that wasn’t going to work. And we can move on to a different mechanism of action from the start.
How does it work for patients?
DR ROSS: It’s a simple, one-time blood test. It does not have to be repeated, and the blood test result comes back usually within a week or two, at the most. The blood test tells you if there is a signal of nonresponse. So, it tells you that this patient is not likely to respond to this class of medications.
Have you been using it successfully in your practice?
DR ROSS: I have because what’s helpful is that a lot of insurance companies demand that the TNF inhibitors be the first-choice drugs. Sometimes, you see a patient that you think will need a different medication, but they will not allow you to give that until the patient fails something else. What happens is, while the patient is not responding to something, that disease is progressing and causing damage which could be irreversible. So, what we have done is if I think a patient is going to need a biologic, I order the test. That way, as soon as the test is back, I say, all right, we can go with a TNF inhibitor, or I can write a letter to the insurance company and say, this patient would not respond. It would be a waste of money and time. We should move on to a different mechanism of action. I’ve had to write quite a few of such letters, and they work. I get them approved because the test has been scientifically proven, it has been approved, and therefore it is something that I can use as a very valid and strong argument to put my patients on proper therapy.
Is the test covered by insurance?
DR ROSS: Right now, the test is being submitted to insurance approval and it is being submitted for Medicare approval. They are in a stage where the patients are still not having to pay for the test. Some insurance companies are beginning to pay for it, and we are hoping that Medicare will soon adopt the test because it saves a tremendous amount of money in the long run.
Can you tell us a little bit about your patient, Regina?
DR ROSS: Regina has rheumatoid arthritis and it’s fairly severe. When we decided to move on to a biologic, I ordered the tests for Regina and the test came back showing that she would not respond to a TNF inhibitor. So, I was able to use that information to convince her insurance company that she would need a different medication. We were able to start something that seems to be helping, and we are working on it. Unfortunately, what we don’t have yet, the true holy grail is going to be who can we guarantee will respond to a certain treatment? So, there is still some trial and error, but a test like this that saves a 12 – to 16-week period of trial and error is really helpful. And with her, we were able to skip that time.
Do you do the testing here in the lab?
DR ROSS: No.
Where do the patients go to get blood work done?
DR ROSS: We draw the blood work here in the office and we send it out to Scipher, where the test is run. It is run at the Scipher Lab.
Is there anything else that you would want people to know, either about rheumatoid arthritis or about the PrismRA test?
DR ROSS: I think the important things to know about rheumatoid arthritis is that it is a highly treatable disease. It is a systemic disease. It’s not just a joint disease. The immune system and the whole body are at war, which can have very grave consequences, including cardiovascular diseases, early mortality, cancers, and such. We have the power to make a huge difference. We can use medications that can bring the disease into remission in many cases. By having a test like PrismRA, that has allowed us to do it faster, to be able to be more efficient at deciding who is a good candidate for this drug or that drug.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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