Expert view: How personalised is autoimmunity in 2019?
The ultimate goal of modern medicine is a personalised approach for the individual patient, that is, a tailored management based on a finely tuned definition of immunogenetics, epigenetics, microbiome, and biomarkers, to maximise results and minimise risks of treatment (particularly of new biologics and small molecules).
As in the case of rheumatoid arthritis, current treatment choices are largely based on minor determinants, while a trial-and-error approach remains largely utilised. While the development of objective criteria might appear an overambitious goal, we note that our current genotyping capacity, the proteomic tools, and the examples of rheumatoid arthritis and other autoimmune diseases are strongly supporting the likelihood of the success of this hypothesis. Indeed, biomarkers are central to this pathway. Among individual factors around which to tailor the patient management are sex and age, with gender-medicine finally becoming central to the research agenda.
Genetics data have thus far been of limited use in clinical practice, whereas we are expecting major developments from synovial tissue histology, which has been largely overlooked in the past years and will become central with the growing number of mechanisms of action of treatments (that is, TNF alpha, IL6R, JAK, CTLA4). Among individual factors, the role of anti-citrullinated peptide antibodies to discriminate a more aggressive and erosive disease is established, while a renewed understanding of the reproductive factors involved in rheumatoid arthritis, considering its striking predominance in females, is great news in the field. Finally, current research efforts are dedicated to lifestyle changes that might impact disease phenotype, such as weight loss or undertaking physical exercise.
The management and treatment of rheumatoid arthritis is becoming more individualised thanks to a special combined effort of basic scientists and clinicians, and, as a result, more answers are becoming available for patients who inquire about the progression and natural history of their condition.