Francisco J Blanco, MD, PhD, Spain

As new therapies are approved for RA, we must consider where they best fit into the overall treatment strategy. Treatments with the MOA of JAK inhibition (JAKi) were introduced relatively recently and have been typically used after biologic failure.1 Registry data presented at the ACR Convergence 2020, showed that patients treated with JAKis tended to have prior experience with biologics.2,3 However, the most recent updates of the EULAR and the ACR guidelines, which were presented at this meeting, recommends using biologics or JAKis in patients after MTX failure 4,5 To discuss this issue, Vibeke Strand and Michael Weinblatt, both from the US, debated where JAKis should be placed in the treatment paradigm during the session called “The Great Debate.”6

Dr. Strand presented the argument in favour of earlier line use of JAKis. To make her case she argued that JAKis have:

  • Robust head-to-head data, where JAKis demonstrated both superiority and non-inferiority against adalimumab
  • Rapid onset of action
  • Improvements on PROs
  • A short half-life, which allows for treatment interruption when adverse events emerge
  • An increased incidence of herpes zoster. However, she commented that she often recommends vaccination in her patients receiving JAKis

She pointed out that JAKis are associated with an increased incidence of herpes zoster and venous thromboembolism events. As a result, she recommended considering patient risk factors and assessing vaccination status.

Dr. Weinblatt firmly disagreed and instead suggested that 22 years of clinical experience with biologics could not be overcome. He felt that biologics should be used ahead of JAKis because rheumatologists know what to expect with biologics regarding their:

  • Efficacy
  • Time to response
  • Safety profile
As shown in the chart, it seemed the audience agreed as 68% of them also felt JAKis should be used after biologics in patients who have failed MTX.

Personally, I think both presenters made strong arguments. In my practice when I’m deciding on the best treatment approach for a specific patient, I also consider:

  • Patient preference
  • Shared decision-making
  • Patient characteristics, such as age
  • Comorbidities
  • Risk factors (smoking and medical history)

I also like to take the recommendation of incorporating a treat-to-target strategy (highlighted in the new ACR guidelines), into consideration. If my patient is not responding to their current therapy, I work with them to consider moving them to another therapy, another topic also highlighted on this blog site.5,7

In the end, I believe we can all agree the field of rheumatology is lucky to have multiple efficacious and tolerable options to offer our patients, a point echoed by both presenters during this year’s Great Debate.

Be sure to read Dr Bernard Combe’s blog on the updates to the ACR guidelines to hear additional perspectives on treatment strategies in RA. Also, check back for continued commentary and discussions in a podcast led by several rheumatologists from the UK, coming soon to this site.

Francisco J Blanco, MD, PhD
Scientific Director, INIBIC- Instituto de Investigación Biomedica da Coruña, Spain
Rheumatologist and Professor of Medicine, Universidad de A Coruña, Spain

ACR, American College of Rheumatology; EULAR, European League Against Rheumatism; JAKi, Janus kinase inhibitor, MOA, mechanism of action; MTX, methotrexate; RA, rheumatoid arthritis.

References: 1. Harrington R, et al. J Inflamm Res. 2020;12:519-531. 2. Kishimoto M, et al. ACR Convergence 2020. Poster [abstract 0803]. 3. Movahedi M, et al. ACR Convergence 2020. Poster [abstract 0830]. 4. Smolen JS, et al. Ann Rheum Dis. 2020;0:1-15. 5. Fraenkel L, et al. ACR Convergence 2020. Presentation [session 5M018]. 6. Strand V and Weinblatt M. ACR Convergence 2020. Presentation [2F008]. 7. Smolen J, et al. Ann Rheum Dis. 2010;69(4):631-637.