How well do Biologic medications help Rheumatoid Arthritis?
Biologic medicines for RA: The Humira team?
I remember when my rheumatologist explained Humira to me. She drew pictures to show me how the molecule in the medicine interfered with the process of Rheumatoid Arthritis. She said that the molecule in the drug locked onto an antibody molecule, effectively neutering the immune molecule.
It sounded more like football than medicine. So, that is why they call Humira a TNF-blocker. Maybe they should give out jerseys in that nice new patient box with the videos.
Do Biologics work better? The TEAR trial
A lot of noise is being made about the TEAR (Treatment of Early Aggressive Rheumatoid Arthritis) study which was discussed last week at the big meeting in Philadelphia: the Scientific Meeting of the American College of Rheumatology (ACR) in combination with the European League Against Rheumatism (EULAR). The TEAR trial has been interpreted as evidence that older DMARDs can work as well as a modern Biologic medicines (with methotrexate) if the DMARDs are used as a combination of 3 medicines (methotrexate, sulfasalazine, and hydroxychloroquine) at once.
Biologics and Rheumatoid Arthritis: Conflicting evidence
Those results were surprising since previous studies have shown the opposite result. For example, just this August, the Swefot (Swedish Pharmacotherapy) Trial measured how 3 (again, methotrexate, sulfasalazine, and hydroxychloroquine) DMARDs literally stacked up against a TNF-blocker (used in combination with methotrexate) to treat moderate to severe Rheumatoid Arthritis. One scientist said that the studies will be dissected in search of methodological flaws.
Methotrexate is the linebacker
As a layperson who writes a blog about Rheumatoid Arthritis, I see one glaring fact: every patient in every study that I examined was given methotrexate. Every medicine for Rheumatoid Arthritis is shown to be more effective if used in combination with methotrexate. It reminds me of getting a portrait made with good lighting and wind effects; the subject is much more attractive.
It looks as if the doctors and scientists who conducted the studies thought it immoral (malpractice) to withhold methotrexate from patients living with the consequences of Rheumatoid Arthritis. They aren’t lab rats, after all. Methotrexate is the most effective medicine we have up to date. However, only a small percentage of RA’ers achieve clinical remission on methotrexate alone and methotrexate alone is less effective at preventing radiological progression (read: damage).
When the RA drug ads are telling you how wonderful life will be with their medicine or how you can get your life back, listen carefully. They all say, “When used in combination with low dose methotrexate.” When a print ad selling Biologics says how well it works, read the fine print: they are expecting the patient to be taking methotrexate. That is in their literature.
Biologics are sold to work with methotrexate because, studies have repeatedly shown that Biologics work with methotrexate (two examples are Humira and Enbrel). “Work” is defined by greater clinical improvement of symptoms and fewer radiographic changes (erosions visible on x-rays).
A shot in the dark
Rheumatoid Arthritis is an extremely complicated disease. Scientists have only a few snapshots of how it works to attack the body. The exact mechanisms and causes are not known. However, Biologic medicines target various components of the immune system by either blocking some cytokines or suppressing lymphocytes (B cells).
Water on the fire
On the other hand, methotrexate is more like a wet blanket on the whole immune system. Since it inhibits cell reproduction, it inhibits immune function, inhibiting RA. That is probably why it also slows synovitis.
We may be a long way from a cure, but we are a very, very long way from where we were 20 years ago.
Recommended reading:
- Methotrexate and Rheumatoid Arthritis
- What Causes the Fatigue of Rheumatoid Arthritis?
- Do You Take Methotrexate for Rheumatoid Arthritis?
- Psoriatic Arthritis
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I use only enbrel for severe RA. MTX made me too sick and I was catching EVERYTHING…since I am a public school teacher that was terrible! Enbrel has worked well for me thus far..I keep waiting for the “fade” to begin.
Like Amy, MTX made me sicker than a dog and I now only use a biologic (Enbrel for five months until the “fade” began, now on Cimzia). But I’m sure that a combo of MTX and a biologic would be more effectve.
Sorry to hear that. I have been very sick from Mtx, too. I call it the “kicked by an elephant” feeling. I am so grateful that my RD at that time encouraged me to not give up. Back then I had no idea about all of this… She was right & FOR ME anyway, the side effects subsided eventually. They do come back, but usually only for a few hours or a few days at a time.
Kelly, I think you are amazing. I have learned more about my RA in the last few months by following you. I so believe that we need to be Managers of our RA…so thank you for the education.
Kelly, I agree, we shouldn’t have to be lab rats. But sometimes I feel medicines are rushed through to quickly without adequate studies done. For me, it’s plenty sobering just contemplating changing to a drug that has been around for a while, but in 2006 the FDA issued new standards for speeding up drug tests in order to trim costs for drug companies.
http://www.bg-medicine.com/content/news-center/news/q/id/24
I haven’t read it yet. Thanks for posting. Terry, I’m wondering if FDA speeding up the process is not also going to help patients to get more meds, better meds, less expensive meds for us too. We all demand that, but we don’t realize how impossible the RA puzzle is to scientists. (Being the optimist…
BTW: Feel the same sobering thing about taking a new drug next month… What helps with that is the sobering truth about RA itself…
Thanks for the interesting blogs! Unfortunately my drs won’t touch me with the biologicals-too many issues with my blood counts. I keep hounding them though
I do know that they help others and am always interested in how long RAers see results
I am just started Humira (today), and I am not sure what to expect. I am still not sure what to expect with RA, period. We are a long ways from a cure, but we are not dead either. Each person needs to find out what works them, and well, I am still not convinced the RA remission exists.
Wow, what a day for you Lana. Good luck to you!! Let me know how you are doing…
Agreed about remission. I haven’t had a break in flare in almost 4 years. Sometimes, I feel even other RA’ers don’t get what I mean…
ditto to Jana.
Kelly, you know, I was just as you are now- I did not get a break from my RA from 2005 until early Oct of this year, and now BAM… I am feeling better everyday… go figure.. and I mean it was everyday — with no days off
Technically, one more reason for combining methotrexate with biologic agents is to prevent development of antibodies to the biologic agent. Methotrexte tends to prevent formation of these antibodies. The antibodies are in turn responsible for the ‘fade-off’ effect when biologics are used over a period of time.
Yes, I’ve read that idea. THANK YOU, doctor, for pointing out a very important reason that we might re-consider low-dose methotrexate to make the Biologics work better / longer.
Many of us get RA when we are pretty young, and it is very likely to “run out of options” faster than new medicines become available. So, it’s important to be able to use a medicine for as long as possible (as long as it can work).
BTW,
there was some interesting discussion on the Facebook page about this point:
Manufacturers of these medicines would LOVE to be able to produce a Biologic that works just as well without methotrexate. I am sure that they’re trying to do that.
Actemra (Tocilizumab) is probably the first biologic to be tested ‘head on’ with methotrexate. The AMBITION study looked at tocilizumab alone (without additional methotrexate) v/s methotrexate. The results were reported in March 2009. This probably would be the first biologic to be tried without additional methotrexate. But it’s too early to conclude. Details of the study at http://arthritissupportboard.com/actemra_clinical_trials.aspx
I just started with a new injection called Simponi or golimumab that is combined with MTX. It is injected once a month. Anyone else out there trying this? Seems to be making a big difference although I am recovering from a recent fall and when those sores heal I’ll have a better idea. Like to know if others are being offered this and any news or information about Simponi. It is very expensive $1,950 per shot if uninsured and fortunately, knock on wood I still have insurance even though we have to make tough financial decisions every month in order to keep it… you know the story.
That’s a funny one “the FDA issued new standards for speeding up drug test – to help trim cost for the drug companies”? Those poor drug companies.
Now their just getting richer faster, and its no wonder most of Congress has stock in drug companies. So they can pass laws to profit themselves. Sure they do!
So, who is helping to get the cost of the drugs cheaper for people who’s lives depend on them, now that the drug companies can make them cheaper and faster? No-one!
And I supose you think the meds are safer now that we get them faster, because they must be getting better at making them? Right? The only reason they tell you the drugs have so many side effects (because they are so bad for you) while making them sound like a cure from above is so you can’t sue their fancy trousers off!
Reality check for you! Rich people are not honest! Rich people help themselves first! Rich people file false reports all the time! Rich people arn’t rich because they give things away! Drug companies are just more Rich people getting richer off of others peoples misery!