Reflections on the 2017 ACR Congress

This year the American College of Rheumatology (ACR) annual scientific congress took place in the city of San Diego, CA. Those who have regularly attended the ACR meetings will undoubtedly have remembered previous editions in this beautiful city. Each time one visits San Diego it is striking how much it develops, and just as striking is the fact that the weather is always perfect! And so whether strolling to and from the convention center, or meeting for scientific or social reason in the downtown area or elsewhere, congress attendees could feast on generous sunshine and comfortable temperatures until late in the evening.

Once again, the ACR congress (along with the Allied Rheumatology Health Professionals, ARHP) was large (14-15,000 attendees), well-organized, busy, successful, and informative. For a single attendee it was entirely impossible to keep up with the enormous flow of information that was poured out during the official 3.5 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 personal one.

As has traditionally been the case, during this congress the Editorial Board of Lupus Science & Medicine met to discuss how our journal is progressing. This meeting was very pleasant and productive. We were pleased to be able to discuss the success our journal has in publishing outstanding original research papers as well as reviews and other communications, and we noted the steady growth of citations, a very high number of views and downloads, and a rather remarkable presence of our publications on social media channels.

The Open Access format of Lupus Science & Medicine is widely seen as a step in the right direction, whereby every published article is immediately available for reading and downloading by anyone who wishes to do so, be it a physician, researcher, patient or other interested party. In this way, the dissemination of research results is very fast and world-wide, and our journal is helping to bring more information about lupus to physicians in all specialties, in keeping with our mission to provide a platform for all those who have a genuine interest in advancing the knowledge of SLE and providing a better future for our patients with that elusive disease.

Many interesting new research findings on SLE were presented for the first time at the ACR congress. One of the most noted presentations described the development of new classification criteria for SLE, an initiative under the auspices of both ACR and EULAR. New criteria were derived in a large cohort and will soon be tested in a confirmation cohort, after which they may become the official classification criteria for this disease. Exactly how much better they are than the established ACR criteria, or how they compare with the SLICC criteria, remains to be seen. And as always, these criteria are intended for use in clinical research and should never be used blindly to make a diagnosis.

Another interesting presentation dealt with the treatment of very severe SLE and lupus nephritis. In an open study, patients were treated with rituximab (“induction”) and after that with belimumab (“maintenance”). The majority of patients seemed to have responded very well to this treatment.
I myself had the pleasure of presenting a late-breaking abstract with the results of a phase II clinical trial with ustekinumab in SLE. Ustekinumab is a monoclonal antibody that blocks both IL12 and IL23, and it is an approved treatment for psoriasis, psoriatic arthritis, and Crohn’s disease. The trial I presented was done in patients with SLE who had active disease despite conventional treatment, and the results show that after 24 weeks of treatment patients on ustekinumab did significantly better than those on placebo. Because ustekinumab is a well-established drug with a good safety profile this could be very good news indeed for patients with SLE. However, as always these results will first have to be confirmed in a larger phase III trial.

For me there were also several other 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. 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. At this time, US rheumatologists are getting more and more experienced with the approved drug tofacitinib, while European colleagues have just this year received the green light for using both tofacitinib and baricitinib.

Osteoarthritis has long remained a disease with very few medical therapeutic options, other than symptomatic relief. This may now be changing. A late-breaking abstract reported on a clinical trial with injections of sprifermin into the osteoarthritic knee, and another trial with an oral Cathepsin K antagonist in OA was presented as a poster by Conaghan et al. In both trials, the intervention was shown almost completely to halt the progressive loss of cartilage that is the hallmark of the disease. If these results are confirmed, we may soon see the emergence of true “disease-modifying” drugs for OA.

The topic of biosimilars received a lot of attention at this congress, not least through a “Great Debate” on the topic. Clearly, biosimilars have entered the rheumatological therapeutic armamentarium, perhaps more so in Europe than in the USA. The “point” of having biosimilars is quite clear: it is not so much the well-being of the individual patient, but the perspective of major cost reductions for this expensive class of drugs. Those who are most idealistically-minded will argue that this should make biological medications available for more patients, both in the individual countries and worldwide. More cynically inclined colleagues will argue that the financial benefit will be picked up by the health insurers and hardly benefit the individual patients at all. I hope the idealistis will at least be partly correct!

On this topic, new data from the Danish DANBIO registry were presented. In Denmark, switching from the more expensive “originator” to the less expensive “biosimilar” has been made mandatory, and the registry tracks the results in practice. It turns out that the vast majority of patients (>90%) had no discernible worsening after such a switch. Those few patients who do experience a worsening may well have a naturally occurring flare rather than one caused by the switch, or even a genuine “nocebo” effect – the worsening of disease in anticipation of an intervention seen as negative. Taken together with many other data, these results would support the practice of switching under close monitoring of the patient.

All in all, this was an excellent congress. I cannot help mentioning that the Amsterdam Rheumatology and Immunology Center was very well represented, with several oral presentations, and many more posters. We hope to continue this tradition next year in Chicago, and to see you all there!

Ronald van Vollenhoven
Director, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
Co-Editor-in-Chief, Lupus Science & Medicine

Conflicts of interest
In the past two years, I have received:
– research support and grants from: AbbVie, BMS, GSK, Pfizer, UCB
– consultancy fees or honoraria from: AbbVie, AstraZeneca, Biotest, BMS, Celgene, Crescendo, GSK, Janssen, Lilly, Novartis, Pfizer, Roche, UCB