“As we increase our understanding of the immunologic continuum from a healthy immune system to preclinical rheumatoid arthritis to early and chronic disease, new opportunities for individualized interventions that treat or prevent disease should emerge,” conclude authors of a review article. “Interceding at the earliest time points to prevent disease will perhaps be as important as identifying new targets for long-standing rheumatoid arthritis. New classification criteria are needed to harmonize data from clinical trials and observational studies involving at-risk persons. At the same time, analyses of multiple streams of genomic, proteomic, metabolomic, and epigenomic data are likely to identify new therapeutic targets and enable clinicians to select the agent that will work best in an individual patient.”
While some immunologic conditions such as psoriasis have a dominant pathway through which disease emerges, “rheumatoid arthritis has multiple potential paths to a common clinical presentation,” the authors write. “The disease progresses from preclinical rheumatoid arthritis through chronic disease and involves pathogenic pathways and cell lineages that can differ among patients, complicating therapeutic efforts. The predominance of certain pathways over others in individual patients is underscored by the diversity of clinical responses to targeted therapies, despite a remarkably similar clinical phenotype. There have been revolutionary changes in the treatment of rheumatoid arthritis in the past three decades, but many patients still have persistent disease. The ability to identify the specific pathogenic mechanisms in individual patients would improve outcomes by directing therapy to those targets.”