For many people, the fear is there from the first joint pain: what if it was the start of an illness that could handicap them for the rest of their life? Facing the
rheumatoid arthritisan autoimmune disease that is still incurable, a question often comes up: can we act before it really sets in to gain years of respite?
This inflammatory disease affects between 0.5 and 1% of the adult population; in 2019, 18 million people suffered from it worldwide. It causes painful, hot, swollen joints and, without treatment, can lead to irreversible damage as well as heart or lung damage. A team from King’s College London today brings an important piece to the puzzle: a early treatment for rheumatoid arthritis in people at very high risk could delay the onset of the disease for years. Sometimes up to four years.
One year of abatacept in adults at high risk of rheumatoid arthritis
Although there are effective treatments for people with proven rheumatoid arthritis, there are currently no approved treatments to prevent the onset of the disease in people at risk.
In the APIPPRA trial, researchers recruited 213 adults from the United Kingdom and the Netherlands with inflammatory joint pain, without frankly swollen joints, but with very specific autoantibodies (ACPA and rheumatoid factor) detected by blood test. This profile corresponds to a so-called “at risk” phase, or pre-polyarthritis, during which the probability of developing the disease within two years is particularly high.
Participants received either theabatacept by weekly injection for 12 months, or a placebo. After one year, only 6% of those treated had developed rheumatoid arthritis, compared to 29% in the placebo group; at 24 months, these proportions were 25% versus 37%. During treatment, pain, fatigue, sleep and ability to work significantly improved in patients who received abatacept. As Professor Andrew Cope, Professor of Rheumatology at the Rheumatic Disease Center at King’s College London, summarizes: “Intervening early in people at high risk of rheumatoid arthritis may have lasting benefits. We have demonstrated that this approach is safe and helps prevent disease during treatment, while significantly relieving symptoms. Above all, it can delay the onset of rheumatoid arthritis for several years, even after treatment has stopped. This could reduce the length of time people live with symptoms and complications, significantly improving their quality of life“.
Delay the onset of the disease, without making it disappear
Extended follow-up, between four and eight years, shows that the benefit does not stop with the last injection. People who received abatacept took significantly longer to develop rheumatoid arthritis than those on placebo, with a delay of up to four years after the end of 12 months of treatment. The effect was particularly marked in individuals at the highest risk, identified by autoantibodies very present in the blood. In contrast, once treatment was stopped, symptom levels gradually approached between the two groups, suggesting that continued immune modulation may be necessary to maintain symptom control.
Researchers speak of a “suspensive” effect: the treatment modifies the course of the disease by postponing its appearance, but does not permanently prevent it. Gaining several years without inflammatory flare-ups or significant disability, however, remains a major challenge for professional and family life and long-term health. The safety data are rather reassuring: the rates of serious adverse events were similar between abatacept and placebo, with no particular signal linked to the drug, even if regular medical monitoring remains essential.
What does this change for patients in France?
In practice, abatacept (Orencia ®) is already used in France to treat established rheumatoid arthritis, especially when a first traditional basic treatment has not been sufficient. For people only “at high risk”, with joint pain and autoantibodies but without swollen joints, there is currently no routinely authorized preventive treatment. Learned societies remain cautious: many at-risk subjects will never progress to true polyarthritis, while biotherapies are cumbersome, expensive and still carry an infectious risk.
For someone who has repeated joint pain, especially in the morning, or a family history of polyarthritis, the issue today is to first consult a rheumatologist early. This specialist will be able to assess the level of risk, prescribe the necessary examinations, organize close monitoring and quickly begin basic treatment as soon as the polyarthritis becomes clinical, in order to limit joint damage. For a minority of very high-risk patients, participation in a clinical trial testing an early treatment such as abatacept may sometimes be offered, always under strict medical supervision.