Research Round Up

There have been lots of news stories about new treatments for arthritis this week so I thought I’d try and summarise some of the research here.

Apremilast, I haven’t heard of it, but apparently it has been tried on 204 people with psoriatic arthritis and the results were reported at the American College of Rheumatology.

http://www.arc.org.uk/news/article/19419802

You can read the abstract here:

http://acr.confex.com/acr/2009/webprogram/Paper11462.html

If you read the abstract, you will be pleased to note “there were no deaths” !

This also lead me to a link in Nature Drug Discovery, this graph interested me, it is the number of people with mild, moderate and severe psoriasis and the treatments they receive.

http://www.nature.com/nrd/journal/v8/n10/full/nrd2996.html

You can download the pdf here:

http://www.nature.com/nrd/journal/v8/n10/pdf/nrd2996.pdf

This is a summary table I’ve drawn up using the information in the article

How does it work?	Marketing Name	Scientific Name	Company that makes the drug	Get it by…
Inhibits TNF alpha	Humira	adalimumab	Abbott
	Enbrel	etanercept	Amgen/Wyeth/Takeda
	Remicade	infliximab	Centocor Ortho Biotech/Schering-Plough	IV infusion
	Simponi	golimumab	Centecor Ortho Biotech
Target T cells	Raptiva (Xanelim)	efalizumab	Genentech/Roche/Merck-Serono
	Amevive	alefacept	Astellas/Biogen
IL-12/ IL23 Inhibitor	Stelera	ustekinumab	Centecor Ortho Biotech
PDE4 and other interleukins		apremilast	Celgene	Tablet

Withdrawn

There are certainly lots of new drugs out there. But and it’s a big but, they all target general pathways that your cells use to signal (communicate) with each other and long term, no one knows what these drugs are going to do to you.

TNF was discovered because it could kill tumour cells, therefore, it’s possible that if you inhibit TNF you increase your risk of cancer.  So far, after 6 years of follow up, people taking TNF inhibitors are NOT at an increased risk of cancer.

However, cancer takes YEARS to develop and until we have data looking at 20-30 years we’re not going to know if these drugs do increase your cancer risk.  For example, being obese increases your risk of cancer.  About 40 % of cancers could be prevented if people maintained a healthy lifestyle. If you are obese in your 20’s and 30’s you are not going to get cancer (due to obesity). If however you are in your 60’s or 70’s you ARE more likely to develop epithelial cancer because you are obese.  I think the same will be true for the TNF inhibitors.  They won’t give you cancer straight away, but over a lifetime they probably will increase your risk.  Whether the risk of developing cancer is worth being able to live your life in minimal pain and with much greater mobility for 20 years is a decision people who need the TNF inhibitors have to make.

The National Psoriasis Foundation in the US, have a good list of new drugs for psoriasis, whether these will be apporved by NICE/SIGN for use in the UK is a different matter entirely…

http://www.psoriasis.org/NetCommunity/Page.aspx?pid=664

There was also some new research out this week describing how fish oils could help arthritis:

http://www.arc.org.uk//news/pressreleases/18445.asp

http://www.wellcome.ac.uk/News/2009/News/WTX057226.htm

http://www.sciencedaily.com/releases/2009/10/091028142227.htm

The science bit….

http://www.nature.com/nature/journal/v461/n7268/full/nature08541.html

Arthritis or Cancer?

One of the treatments for severe psoriatic arthritis that has failed to respond to other treatments (e.g. methotrexate or sulfa) is a TNF inhibitor (Humira, Enberel or Remicade).  TNF stands for Tumour Necrosis Factor.  Necrosis is a type of cell death.  If you have any cancer cells in your body you want them to die. So, TNF is a “factor” (or thing) in your blood that tells tumour cells to die (in some cells, under some circumstances)

You would think TNF would be a good thing to have.  However having too much TNF is one of the reseasons people with inflammatory arthritis (like psoriatic arthritis, rheumatoid arthritis, or ankyolysing spondylitis) have joint damage.  If you reduce the amount of TNF in a person, you stop the joints (and possibly the tendons) from being damaged and destroyed.

The trouble is TNF inhibitors seem to cause cancer.  The experts argue, some people say it doesn’t cause cancer it just makes cancer you already have obvious.  As most cancer take 10 years or more to develop, it does seem logical that the TNF inhbitors could uncover cancers that people have but didn’t realise it.

Often people taking TNF inbitors also take other drugs that may also increase their cancer risk and even having rheumatoid arthritis alone, without treatment, increases your cancer risk so it is difficult and complicated to research this.

If is thought that the TNF inhibitors increase your risk of lymphomas.  If you have lymphoma you may  be fatigued (very tired) and lose weight, but these can also be signs of inflammatory arthritis.  There is more about this on the Arthritis Research Campaign website “Cancer Screening – should be offered to people on anti TNF drugs“

In the US the warning labels on the TNF inbhitors are to be changed to say that these drugs can increase your risk of cancer and can cause, or worsen psoriasis. You can read more about this and read further links on the NHS Choices page “Immune Drug Linked to Cancer“

Cancer can take decades 10-30 years to develop, TNF inhibitors have only been used for about 8 years.  I think if we studied people on TNF inhibitors for 30 odd years we will see an increase in cancer, in some (although not all) people who take these drugs. Which is worse, a life crippled by arthritis or cancer?  Some types of cancer can be treated very successfully.  Others can’t.

Could I chose to take a drug that could give me cancer?  How bad would my quality of life have to be before I would consider that? Which is better a short and productive life, or a long pain-filled one?  Is it ever that simple?

Could I live with my own decision either way?  Would I regret taking a TNF inhbitor and blame that if I developed cancer?  Plenty people get cancer without taking TNF inhibitors, I could develop it anyway. Would I regret NOT taking a TNF inhibitor and not being able to play with my kids and look after my family because I was so fatigued and in so much pain?

Who knows?  How can you know? I guess I’ll just have to cross that bridge IF I come to it.