The ACR congress also featured, as it always does, a lot of exciting activities and new findings on SLE. Lupus gives up its secrets only very slowly, but there were many presentations from researchers working on elucidating the etiology and pathophysiology of this disease. I was most impressed by results from different groups that point at potentially important roles for extracellular vesicles in SLE. I was also pleased to see how many clinical researchers were analyzing the prevalence of remission in SLE using a newly developed framework. There were no major new therapeutic successes reported at this congress, but there is high anticipation for the continuation of the earlier promising results with therapeutics that target the interferon pathway. For me, another highlight was the Editorial Board meeting for the still young open-access journal Lupus Science and Medicine. Together with Dr. Jill Buyon from New York I have the honor of being editor for this publication, which is supported by a partnership between the Lupus Foundation of America and the BMJ publishing group. We are now entering our third year and the Editorial Board unanimously felt that the journal has had a most exciting and promising development, with more than 170 manuscripts submitted and many very interesting and often cited results having been published already in this short time.
The 2016 ACR congress took place in the aftermath of the US presidential election and at a stone’s throw of the White House, in Washington DC. And while the rheumatologists who attended the congress may have had mixed feelings and opposing views on the political situation (and few speakers failed to make wisecrack references to this) they all agreed that the congress was another very successful, informative and – in some ways – groundbreaking event in our discipline.
For a single attendee it was entirely impossible to keep up with the enormous flow of information that was poured out during the offical 3½ days of the congress (and not counting the courses and meetings preceding and following the main program), so any reflection is by necessity an incomplete and somewhat biased one.
For me there were several stories of considerable interest. Perhaps the most obvious “big” story is the advancement of JAK inhibitors for rheumatoid arthritis. Many trials were being presented on several different compounds, all confirming the very good efficacy of this class of drugs, in some instances even surpassing TNF inhibition. Side effects and safety are different between JAK inhibitors and TNF inhibitors, and rheumatologists will have to keep this in mind, but hopefully having more therapeutic options will allow patients to do better. As US rheumatologists are getting more experienced with the approved drug tofacitinib, European colleagues are waiting to see if it will be approved there as well, and on both sides of the Atlantic the possible approval of baricitinib is also awaited.
Another big ongoing development is the advent of IL17 inhibitors for psoriatic arthritis and spondyloarthritis. There were trials with secukinumab which is already approved in rheumatology, ixekizumab which is approved for psoriasis and may become a second approved drug for the rheumatological indications, and several other agents in clinical development. Overall the efficacy of IL17 inhibition is impressive and rheumatologists are becoming more familiar with the safety and side effect side. The same can be said for apremilast, for which several observational studies confirm previously noted efficacy and safety aspects.
A major new development was the GIACTA trial that was presented in a plenary session. It tested the efficacy of the IL6 antagonist tocilizumab in giant-cell arteritis and demonstrated impressive results, allowing a much greater proportion of patients to taper corticosteroids without flaring. Following in the footsteps of a much smaller Swiss study published earlier this year, it seems clear that IL6 blockade is an effective intervention in this disease. However, the safety will have to be evaluated in larger numbers of patients and over longer periods of time in this population of patients who frequently have considerable comorbidities. Another major question will be to what extent these results can be extrapolated to polymyalgia rheumatica.
Another very important trial was presented, rather oddly, as a poster: the NOR-SWITCH trial. In this randomized and blinded trial, patients who were doing well on infliximab from the brand Remicade (the “originator”) were continued on the originator or switched to infliximab from the brand Remsima (the “biosimilar”). The trial showed that the clinical results in the patients with RA and other rheumatological conditions were almost identical, suggesting that switching would be medically allowable (for patients with Crohn’s disease, there seemed to be a numerical difference, which will have to be investigated further). However, the trial also demonstrated something else: almost one-third of the patients reported worsening of their disease – even if they had not really switched at all (this is technically known as the “nocebo” effect, the opposite of the placebo effect). This finding points at major psychological and practical issues if payers are going to insist on patients being switched to biosimilars. Stay tuned.
All in all, this was an excellent congress. I cannot help mentioning that the Amsterdam Rheumatology and Immunology Center was very well-represented: it featured on 39 abstracts, including 6 oral presentations. We hope at least to equal this next year in San Diego, and to see you all there!
Ronald F. van Vollenhoven
Amsterdam Rheumatology and Immunology Center ARC
Amsterdam, The Netherlands