The latest data on medications for use in fighting rheumatoid arthritis heralds a new dawn in the treatment of this condition in Britain. It is a dawn that has broken later in England and Wales than much of the rest of Europe, including Scotland, but it should lead to a far greater number of sufferers being able to live a more fulfilling life.

Recent developments in medication, involving drugs that target the disease’s biological mechanisms, have revolutionised the treatment of many people suffering not only from rheumatoid arthritis, but other auto-immune diseases, including ankylosing spondylitis, Crohn’s disease, ulcerative colitis, Behcet’s disease (a most unpleasant arterial disease that causes ulcers of the genitalia and eyes, as well as strokes and heart disease), psoriatic arthritis and psoriasis of the skin.

Although anti-TNF (which stands for tumour necrosis factor) inhibitors have been in clinical use for eight or nine years, it has taken them longer to become established in England and Wales. Even when licensed and approved by the National Institute for Health and Clinical Excellence (NICE), some primary care trusts have been resistant to prescribing them on grounds of cost. Some British specialists have been prescribing them off-licence — on the assumption that the necessary acknowledgement of the value of anti-TNFs and other new drugs will take time to be accepted and that meanwhile the patient’s condition needs treatment.

This week Orencia (abatacept), the first drug to target T-cells in the blood and tissue, has been licensed. Five drugs targeting particular biological mechanisms in RA — biological moderators — have now been licensed and another is under investigation. There are more such treatments in the pipeline.

Clinical experience has shown that although most of this group of drugs has some effect on the conditions responsive to anti-TNF alpha therapy, not all are equally successful in treating these cases. There is considerable patient variability in response, but the greater the choice of drugs available, the greater the chance that one will be found to suit the patient.

Experience has shown that Enbrel (etanercept) and Remicade (infliximab) can usually be recommended, used with methotrexate, in treatment of rheumatoid arthritis that is not responding to other drugs.

Enbrel (etanercept) is used in juvenile arthritis and Remicade (infliximab) in the treatment of adult psoriatic arthritis. Orencia (abatacept) is known to make dramatic improvements in the physical function and general health in cases of rheumatoid arthritis.

The NICE recommendations issued this week will make it easier to switch from one drug to another if the first loses its efficacy or the patient doesn’t respond well.

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