New therapy recommendations for rheumatoid arthritis

SBC: The treatment guidelines have now been updated by the European Alliance of Associations for Rheumatology under your leadership. Why now?

Smolen: Basically, the European treatment recommendations exist because treatment has become much more complex in recent decades. While there used to be only a few options available, several particularly effective drugs were added in the late 1990s and early 2000s. This increasingly raised the question of which drug should be used at which point in time. This is precisely where the recommendations of the European Alliance of Associations for Rheumatology come in: They are intended to provide guidance – for rheumatologists and other treating physicians, therapists, patients and indirectly also for health insurance companies and regulators.

These guidelines are updated regularly because new scientific findings are constantly being added. A particularly large number of research publications are published on rheumatoid arthritis, be it on new drugs, treatment strategies, efficacy or safety aspects. For this reason, the recommendations in Europe are generally reviewed every three to four years so that they remain as close as possible to the current state of research.

These recommendations are not developed in a narrow specialist circle. In addition to European experts, colleagues from other regions of the world as well as patients and representatives of other healthcare professions, such as physiotherapy, occupational therapy or specialized nursing, are also involved. This creates a broad view of treatment practice – and in some ways a framework that is relevant far beyond Europe.

SBC: What is the most important message of the new treatment recommendations for people with rheumatoid arthritis?

Smolen: Perhaps the most important message is that rheumatoid arthritis is no longer about being satisfied with relief. The goal is much more ambitious than it used to be. Doctors today want to achieve as much as possible that pain and swelling disappear, the joints remain functional and no further destruction occurs. This state is referred to as remission – in other words, a normal, healthy everyday life under therapy.

For many patients, it is also important to know that a drug that has been known for decades continues to play a central role: Methotrexate. Although modern and expensive drugs are available today, scientific evaluation shows that methotrexate is still very effective and also plays an important role in terms of safety. It is still the recommended initial therapy, usually in combination with very little cortisone for a short transition phase. The cortisone is intended to help until the methotrexate develops its full effect – and this typically only sets in after a few weeks to around three months.

This is particularly good news for people who have to find their way through the maze of drug names, technical terms and uncertainties. The guidelines provide clear orientation: There is a comprehensible first step that is medically sound. And something else is relevant for your readers: Rheumatoid arthritis affects women two to three times as often as men. This is why the topic is particularly relevant for many women in midlife and old age – and often also for their families.

SBC: How does the treatment actually work?

Smolen: Treatment today follows a very clear principle: Treat to target, i.e. targeted therapy. A specific therapy goal is defined and regularly checked to see whether this goal is being achieved. After around three months, the disease activity should already have improved significantly, and after around six months, remission should be achieved if possible. This disease activity is not only assessed by feeling, but also measured using clear instruments – for example based on the number of painful and swollen joints.

If this goal is not achieved, the therapy is specifically extended. Instead of simply switching to another classic basic medication, a biologic is also used. These drugs attack different parts of the inflammatory process. It is interesting to note that they have a similar overall effect despite the different points of attack. This has a practical advantage: If one medication does not help sufficiently, there are other options that you can switch to.

This is important for those affected in several respects. Firstly, it shows that there is a clearer therapeutic logic today than in the past. Secondly, it means that an inadequate response is not automatically a dead end. And thirdly, it shows that good treatment today is much more structured: Observe, measure, assess, adjust. Especially in a healthcare system that often appears complicated from the outside, this clarity can be very relieving. This is particularly important for many women who are affected themselves and also have family or work responsibilities. They not only need therapy, but also a plan to guide them.

SBC: Why is it important to recognize rheumatoid arthritis as early as possible and treat it quickly?

Smolen: Because time plays a decisive role in this disease. Rheumatoid arthritis is not just rheumatism in the general sense, but a chronic inflammatory joint disease with a pronounced tendency towards joint destruction. If action is taken too late, damage can occur that cannot simply be reversed later. This is precisely why the recommendations emphasize early detection so strongly. The earlier the diagnosis is made and effective treatment is started, the greater the chance of preventing or at least significantly limiting joint damage.

In the past, people often waited longer to treat inflammatory joint diseases. Attempts were initially made to alleviate pain and swelling without slowing down the actual disease process early and consistently. Today we know that this is not enough. As soon as the diagnosis has been established, treatment should be started as soon as possible to specifically contain the inflammation. This is because the first damage can already occur in the first year of illness. Those who are treated early often have a much better chance of a more favorable outcome.

The disease is particularly common between the ages of 55 and 75. This does not mean that younger adults cannot be affected. However, rheumatoid arthritis can take an additional toll, especially in the phase of life in which many people are already confronted with health changes, work-related stress or care responsibilities in the family. This makes it all the more important to take symptoms seriously and not wait too long.

SBC: What message would you like to pass on to those affected and their relatives?

Smolen: A key wish is for patients to be more involved in therapeutic decisions. Good treatment today no longer just means getting a prescription and then waiting. Patients should know what the aim of their treatment is, what options are available and why a particular medication is recommended. It is precisely this shared decision-making process that is important because informed patients are usually more consistent in their treatment.

Patients should know what the aim of their treatment is, what options are available and why a particular medication is recommended. It is precisely this shared decision-making process that is important because informed patients are usually more consistent in their treatment.

One particularly tricky point is stopping medication on your own. Many people feel better, believe they are healthy again and therefore stop treatment. However, this can lead to the disease flaring up again and becoming more difficult to control later on. This is why it is so important never to decide on changes alone, but always to discuss them with the doctor treating you.

SBC: Where do you see the greatest need for improvement in the coming years?

Smolen: An important point is a better understanding of the therapy itself. Many patients ask themselves why a drug such as methotrexate is passed on if it is not effective enough on its own. The answer is that it is precisely the combination with newer drugs that significantly improves efficacy. This logic needs to be explained well so that people can understand their treatment.

At the same time, there are still some patients who do not respond sufficiently to the available therapies. There is still a great need for new drugs and, above all, better ways of predicting at an early stage who will respond particularly well to which therapy. In the long term, of course, the greatest wish remains to learn to understand the causes of the disease so well that one day a real cure will be possible.

Thank you for the interview!