Editorial

A platinum age for rheumatology

On June 14–17, over 14 000 rheumatologists, health-care

decade or so, this concept has been inverted. Intensive professionals, and patients will gather in Madrid, Spain,

intervention, initiated earlier, with conventional and for the European League Against Rheumatism (EULAR)

biological DMARDs is increasingly recommended. Annual Congress. 2017 is a particularly special year for the

Gerd R Burmester and Janet E Pope, in the second paper organisation as EULAR celebrates its 70th anniversary.

of the Series, discuss these evolving treatment strategies Since our inception, The Lancet has been pleased to have

for rheumatoid arthritis. They emphasise the role of shared in the rich history of rheumatology research,

biologics and small molecule inhibitors in the therapeutic including The “Rheumatic Disease”, coauthored by

arsenal, and review accumulating evidence that supports the founding President of EULAR, Mathius Pierre Weil,

an early window of opportunity for diagnosis, as well in 1928 and today’s issue, which highlights recent

as management regimens, such as treat-to-target and innovative developments in therapeutics and

approaches that include rapid intervention, reassessment, management strategies for rheumatic diseases.

and adjustment of medications for patients who do not Much of the recent knowledge of the underlying

achieve remission within 6 months—with the aim of mechanisms that drive rheumatoid arthritis and other

preventing or slowing structural damage. diseases has come from preclinical studies in cellular

Raising awareness of these new recommendations, systems and animal models. Although important and

this year, EULAR launched a new campaign, “Don’t delay, essential research tools, these experimental systems do

connect today”, aimed at patients, general practitioners, not always faithfully reflect human biology. In the first

and specialist rheumatologists alike. Patient involvement paper of a Series on targeted treatments for rheumatoid

in research and clinical decision making is a cornerstone arthritis, Iain B McInnes and Georg Schett take a novel

of EULAR, exemplified by People with Arthritis and and refreshing approach to understanding the molecular

Rheumatism (PARE), one of the pillars of the organisation. pathogenesis of the disease in patients. They review

PARE works with researchers to ensure a patient-centred findings from clinical trials of new biologics designed to

approach to care at all levels, and with patient advocacy target specific immunological pathways, and critically

groups to help to disseminate knowledge across Europe evaluate lessons learned from the success and failure of

and to provide education to patients and their families. these studies. By doing so, McInnes and Schett provide

The rapid rate at which discoveries have emerged over a comprehensive overview of the roles of key cytokines,

the past two decades has brought about a revolution in including tumour necrosis factor α, interleukin 6, and

treatment paradigms for rheumatoid arthritis. Many of granulocyte–macrophage colony-stimulating factor. Insights

these developments have occurred in parallel with or have gained from use of novel Janus kinase (JAK) inhibitors,

helped to inform insights into management of a range which target pathway components downstream of

of rheumatoid diseases, as well as other immunologically cytokine receptors, are also discussed in the paper. JAK

driven conditions. But the question of the feasibility inhibitors tofacitinib and baricitinib are approved for

of implementing early and intensive intervention treatment of arthritis and other rheumatoid diseases.

with new biologics in settings other than high-income Knowing which cytokine and signalling pathways to

countries remains. The NOR-SWITCH study showed non- target in specific individuals is a huge advance, but for a

inferiority for switching from infliximab originator to a complex, progressive, chronic disease such as rheumatoid

biosimilar in patients with rheumatoid arthritis, psoriatic arthritis, the timing of intervention is also critical. Around

arthritis, Crohn’s disease, and other conditions for which 25 years ago, the recommended treatment approach was

infliximab is currently approved. Biosimilars might slow and steady, referred to as “the pyramid”—ie, a base of

provide affordable options for treating rheumatism, but physical therapy and non-pharmacological interventions,

it remains to be seen how effectively the new treatment followed by conservative treatment with non-steroidal

strategies can be implemented on a global scale. anti-inflammatory drugs, then glucocorticoid steroids

An unprecedented range of therapeutic options for and, finally, administration of a conventional disease- rheumatic diseases is now available—the modifying antirheumatic drug (DMARD). Over the past

to make them accessible.

∎

The Lancet

new challenge is

For the “Rheumatic disease” see Articles Lancet 1928; 211: 1002–05

www.thelancet.com Vol 389 June 10, 2017 2263

See World Report page 2276

See Perspectives page 2279

See Articles page 2304

See Series pages 2328 and 2338