Remit and terms of reference
During the past fifteen years there has been a revolution in the management of RA. The introduction of biologic therapies but also the earlier and more aggressive use of methotrexate (MTX) have greatly improved the outlook for patients.
A number of studies have suggested regimes for the management of early RA, such as the COBRA study, the FinRA-Co study, and the impressive BeSt study – which illustrates the potential novelty of academically commissioned clinical research. Some studies have even suggested that ultra-aggressive early treatment may lead to a subsequent sustained remission on DMARD monotherapy (Quinn study). In established RA there have also been landmark studies such as the triple therapy study of O’Dell and the Ticora study. These pioneering studies have provided important messages to practising rheumatologists but there remain areas of significant uncertainty and, at present, there is no agreed algorithm for the management of early RA. In part, this is consequent on the continued lack of good prognostic markers with which to tailor therapy for the individual patient.
However, most studies have provided more questions than answers. For example:
- If ultra-aggressive early therapy switches off RA, how long must this be administered for?
- Is it possible to induce true immune tolerance in early RA, as appears to be the case in type 1 diabetes?
- Should all patients initially receive step-down prednisolone therapy to control inflammation and prevent damage (BeSt study)?
- Are the different classes of currently available biologic therapy equally effective and safe, and when should they be introduced in the treatment algorithm?
- Are there biomarkers that can tell us which biologic therapy is best for the individual patient?
These and similar questions are difficult to answer at local or regional level, and many will not be answered by industry-sponsored studies. Therefore it will take a co-ordinated, national approach to, firstly, define the most important questions and, secondly to design studies that can provide definitive answers to them.