Rationale for TNF Inhibition in Rheumatoid Arthritis

Transcript: Madelaine A. Feldman, MD: For the most part, the TNF [tumor necrosis factor] inhibitors are generally used along with methotrexate. Certolizumab has been able to be used alone. Particularly, we see its use in pregnant women, and it is used without the methotrexate. Most of the other TNF inhibitors are mostly used in conjunction with methotrexate, not only to help with the disease modification but also to help in preventing neutralizing antibodies. In this gentleman, a TNF inhibitor would not be a bad choice.

There are some studies that suggest that patients who have a high CCP [cyclic citrullinated peptide] level do respond fairly well to abatacept. That generally is also used with methotrexate.

JAK/STAT inhibitors—tofacitinib, baricitinib, and upadacitinib—are choices that we can use, followed by the interleukin inhibitors, sarilumab and tocilizumab. There are some studies that suggest tocilizumab monotherapy is just as effective as tocilizumab plus methotrexate.

You know, if we looked at this patient and he didn’t have all those hallmarks of the possibility of fairly quickly advanced disease, in some cases we might consider changing the methotrexate to leflunomide, or adding Plaquenil [hydroxychloroquine]. But because of those hallmarks of worrisome, very aggressive rheumatoid arthritis, at this point it would be the time to add one of the biologics that I just spoke about.

Transcript Edited for Clarity