Bill Nguyen is a 41-year-old
artist who's passionate about his craft. Lately he'd been
frustrated. Rheumatoid arthritis (RA) had robbed him of
the ability to create his signature Chinese paintings,
admired for their fine detail. "I've tried so many treatments
-- but nothing seems to last very long. I sometimes
think I'd give up the one hand if the other would just
be free of pain," lamented Bill. While that trade isn't
possible, a drug trial published in the June 17 edition
of the New England Journal of Medicine (NEJM) offered
hope of longterm relief. This benefit comes at a price
though -- a higher risk of infection.
Of the 121 patients who received
two doses of rituximab -- a monoclonal antibody that
blocks the immune system's B cells -- during the first
two weeks of the study, 52 experienced a reduction in
joint pain, swelling and stiffness that lasted a full
six months. Only five of the 40 patients who took conventional
drugs had the same benefit. Further, this pain relief
lasted for the whole 48-week period of the study.
Tampering with the immune system,
however, is a little like playing with fire. Four of
the 121 rituximab-treated patients became seriously
ill because their immune systems were weakened. This
isn't unprecedented. In fact, this particular Pandora's
box "has been wide open in this respect for many years,"
said lead author Dr Jonathan Edwards of University College,
London. "The most recent licensed treatments for RA
are very immunosuppressive and major infection has been
a significant problem. With rituximab the problem looks
to be less severe but ongoing studies outside the NEJM
trial do tend to indicate the chest infection may be
more common."
It's still unclear whether repeated
use of rituximab worsens the immunosuppression. Similarly
acting RA treatments don't ramp up immunosuppression
over time, but the jury is still out on rituximab. "This
may mean [it] cannot be given over a period of many
years, but more work is needed to address this," said
Dr Edwards.
"Whether the risk is outweighed
by the benefit can only be judged by the patients,"
claimed Dr Edwards. "Different people have different
views on life and the relative merits of risk and freedom
from chronic pain. People with arthritis desperately
want to be free of painful, sleepless nights and fatigue
and stiffness in the day. They also want to be free
of the burden of longterm drug treatment. This is what
we should be aiming for."
|
