What does the future of rheumatoid arthritis look like? What needs to happen to progress therapies beyond where we currently are?  Nicola Garrett caught up with international expert Professor Iain McInnes to find out more.

Progress has been good but we’re not there yet

Speaking to the limbic on the future targets in RA, Professor McInnes said there had been a lot of progress with therapies to treat rheumatoid arthritis over the past 15 years.

The advent of small molecule inhibitors and biologics, together with changes in the way medicines are used, have remarkably altered the outcomes for a large number of people with RA, he said.

“Because we came from such a dark place – it was such a poorly treated and poorly managed disease 15 to 20 years ago – there is a high level of satisfaction with progress; however this doesn’t mean there’s not more to be done.”

While current therapies are effective for a significant number of people living with RA they are not a cure, Professor McInnes explains.

Then there are those patients who are doing okay, but are not able to function to their full potential.

According to Professor McInnes there are two things that need to happen to address these issues.

“We need to look at different strategies of care to establish whether existing medicines can be used more effectively,” he said.

“But there is also a need to understand the disease better and use that new knowledge to create new medicines to add to what we currently have.”

A partnership with industry and science

However this brings up the issue of who will develop these new drugs, given that there are a lot of drugs already in the rheumatology sector.

Understandably, Professor McInnes says, drug developers will need to ask some key questions, such as what opportunities any new medicine will provide to further improve quality of life, expedite and maintain remission or edge closer to that elusive cure.

“I empathise with that view to a large extent so the impetus is on investigators to really try and understand what is driving residual disease activity, why is it that they are not in remission and why is it that those people even if they get to remission are not cured,” he said.

“If we understand that we can go back to the pharmaceutical industry with new targets and new pathways.”

TNF blocking biologics really changed the field because people looked at TNF and its role in disease.

“They understood where it sat in the disease structure and that if we blocked it, the disease might reduce in its activity…and that’s how it turned out,” he said.

Since then there’s been a lot of work done in trying to find those pathways that really do drive the pathology and therefore clinical presentation.

But, says Professor McInnes, there is a need to be efficient as we don’t have unlimited resources.

One way to increase efficiency is to use the power of modern cellular molecular biology to understand the pathogenesis and then use that knowledge.

“In a way it’s making a roadmap of the disease and really it’s like sat nav – there’s probably several different routes but there’s one route that’s a lot smarter than the others,” he said.

“That’s where pathogenesis lead interventions comes from – it’s understanding the matrix of the disease and then threading your way through that complexity to the solution.”

What will the new medicines look like?

New medicines could look like medicines we’ve seen before, or potentially bear no resemblance to their predecessors, says Professor McInnes.

Within the field of biologics there’s a lot of innovation going on targeting RNA species targeting the epigenome.

“When you think about that you begin to understand that probably the way in which we go after the target is part of the innovation,” he said.

“Ultimately we want medicines that are not particularly toxic but are highly effective. But that’s not a new statement, we’ve wanted that forever.”

Professor Iain McInnes is Director of the Institute of Infection, Immunity and Inflammation at the University of Glasgow and serves as the Muirhead Professor of Medicine, and ARUK Professor of Rheumatology.