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Rheumatoid arthritis is a chronic, systemic inflammatory autoimmune disease affecting >1.3 million people in the United States.1 Rheumatoid arthritis is defined as persistent joint inflammation that is marked as joint pain, stiffness, and swelling, resulting in progressive destruction of cartilage in the joints.2 Although rheumatoid arthritis primarily targets the synovial lining of joints, it has extra-articular effects, including the lungs, heart, and blood vessels.3 If untreated, rheumatoid arthritis can lead to permanent joint damage, a decrease in quality of life, and disability. Approximately 20% of patients are retired completely or partially within 2 years of disease onset, and 50% of patients are unable to work after 10 years.4 Furthermore, rheumatoid arthritis may reduce life expectancy between 2 and 18 years.5 As a result, rheumatoid arthritis is a burden on patients' quality of life and health care systems.
Traditional Approach
Pharmacologic approaches have traditionally relied on steroids (eg, prednisone, methylprednisolone), nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen), and disease-modifying antirheumatic drugs (DMARDs) (eg, methotrexate [MXT], hydroxychloroquine).6 Disease-modifying antirheumatic drugs are commonly used in patients newly diagnosed with rheumatoid arthritis.6 Because of its safety profile, long-term effectiveness, and low cost, MTX is the most commonly used DMARD.6 Other DMARDs used less frequently include leflunomide, gold salts, azathioprine, cyclosporine, and minocycline.
Unfortunately, some patients with rheumatoid arthritis fail to respond to DMARD therapy, with up to one-third of patients discontinuing DMARD therapy due to a lack of efficacy.7,8 Thus, newer treatments involving the use of biologicals may provide alternatives to traditional DMARD therapy.
Biological Therapies
Although the precise etiology of rheumatoid arthritis is unknown, evidence exists that proinflammatory cytokines, such as tumor necrosis factor α (TNFα), interleukin-1 (IL-1), and interleukin-6 (IL-6), play a role in the pathogenesis of rheumatoid arthritis.9,10 Thus, biologic agents have been developed to target specific inflammatory mediators of tissue damage. The use of biologics has led to improved outcomes. Although expensive, biologics appear to be cost-effective due to the clinical benefits patients experience.
Etanercept, the first targeted biologic for rheumatoid arthritis, is a TNFα antagonist that was approved by the US Food and Drug Administration in 1998. Since then, other agents have become available: the TNFα antagonists infliximab, adalimumab, certolizumab pegol, and golimumab; the IL-1...