Abstract

Personalized medicine including patients stratification for the best outcome is a major grail in medicine. Rheumatoid arthritis (RA) outcome has dramaticaly improved with the efficacy of synthetic and biologic DMARDs combined with early effective management and tight control targeting remission or low disease activity. However unmet needs are still there and with numerous therapeutic options available making treatment decisions in clinical practice remains challenging. To date no predictive factors of therapeutic response have been identified to guide the choice of a specific treatment in RA patients.

The first recommended treatment is similar for every patients including methotrexate frequently combined with low dose steroids. Anyway, EULAR recommends to guide second line treatment decisions based on the use of prognostic factors of outcome (eg, early erosion, high disease activity, rheumatoid factor positivity, and/or anti-cyclic citrullinated peptide antibodies). In case of bad prognostic features it is suggested the addition of biologic therapy rather than other synthetic DMARDs.

The choice of the biological DMARD is also challenging since all biological drugs currently available show similar response rates, similar safety profile and same frequency of good outcome regardless of their mechanisms of action. One of the major unmet needs in RA is the group of patients for whom anti-TNF agents, usually the first line biologic therapy, have failed. Such patients may be more likely to have less TNF-dependent disease and could benefit from subsequent treatment with a targeted therapy of different class. However, this attractive hypothesis has still not been confirmed by clinical data and the choice of the new therapeutic option may be based on the primary or secondary inefficacy to this first line therapy.

In addition, factors apart from disease activity, and disease severity such as co-morbidities and safety issues, could also influence the treatment options for an individual patient. Finally, since achieving remission is the major objective in the management of RA patients in daily life, predictive factors of remission, such as early therapeutic response, have been identified and may also guide the therapeutic strategy.

In summary, stratifying treatment in RA patients is a difficult task in daily practice and is still mainly based on clinical evaluation.