Predicting and monitoring disease course in rheumatoid arthritis : imaging, biomarkers, risk factors, and integrative medicine

Sammanfattning: Rheumatoid arthritis (RA), the most common inflammatory arthritis, is a chronic, potentially debilitating autoimmune disease that can lead to functional disability, bone erosion, and chronic pain. The modern era of treatment has led to major advancements in treating this condition, especially if patients are treated early within a ‘window of opportunity’ with potent disease-modifying antirheumatic drugs (DMARDs) and a ‘treat-to-target’ approach aiming towards low disease activity or remission. Personalized integrative medicine may lead to further advancements in the care of individuals suffering from autoimmune conditions such as RA through the application of imaging, biomarker and risk factor identification, and integrative manual therapy. After simulating a true radiographic progression control group in several randomized clinical trials, early application of intensive or biological DMARDs was demonstrated to be superior to conventional monotherapy in early RA, and that rheumatoid factor-positive patients on an intensive strategy may benefit more with a half-year induction of anti-tumor necrosis factor (TNF) therapy (Papers I-II). For the first time, it was revealed that the proto-oncogene survivin, expressed in one third of patients with early RA, prevents a sustained clinical response to gold-standard methotrexate. Additionally, further allocation to combination DMARDs may be favorable to the allocation of anti-TNF therapy among survivin-positive patients (Paper III). Lifestyle risk factors were shown to play an important role in early RA disease outcome, and obesity in particular was found to be a strong independent predictor of long-term non-remission, in addition to smoking. Obesity was associated with worse clinical outcomes over time, measured by disease activity, pain, and functional disability (Paper IV). A novel approach was explored with integrative manual mobilization therapy and its potential to further enhance patient care in RA. This was demonstrated through systemic subjective and objective hand improvements – including pain, synovial fluid, and joint space (Paper V). Together with the goal of aiming for early, tight RA disease control, when utilizing imaging tools; identifying biomarkers and lifestyle risk factors; and applying integrative medicine, allopathic practice can move towards even better proactive patient care in RA. Altogether, these findings support the value of incorporating personalized integrative medicine into clinical practice for patients with RA.