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In conversation with consultant rheumatologist Professor Paul Emery

Professor Paul Emery’s illustrious career has seen him influence diagnostics and treatment interventions for rheumatoid arthritis (RA) and improve patient outcomes across the globe. Here, he speaks to Helen Quinn about his career trajectory – including his recent CBE – how best practice has evolved in RA and his hopes for the future of the disease.

It is not an exaggeration to say that Professor Paul Emery has revolutionised the field of rheumatology. His pioneering research has changed not only treatment pathways and clinical outcomes but also the way clinicians think about rheumatoid arthritis (RA).

Throughout his career, Professor Emery has championed strategies for early intervention, pioneered biologic therapies for inflammatory conditions and developed the use of imaging techniques in the musculoskeletal field to prevent or slow the progression of RA. His research and clinical work have led to new treatment interventions which have been adopted worldwide, ultimately allowing patients to live without pain for much longer.

Since 1995, Professor Emery has been Versus Arthritis UK (formerly ARC) professor of rheumatology at the University of Leeds and was director of the Leeds NIHR Biomedical Research Centre from 2009-22. He has published over 1,250 peer-reviewed research articles, and in January 2024, he was appointed Commander of the British Empire (CBE) in the King’s New Year Honours for his outstanding contribution to rheumatology.

From his office in Leeds, Professor Emery says he was delighted but taken aback to be awarded the CBE – following his OBE in 2018 – which recognised his work in the UK and internationally. ‘One of the things I like is that I was given it for services to rheumatology, which is rather unusual. I’m quite proud of that. I was very surprised,’ he explains.

Making waves in rheumatology

Professor Emery studied at the University of Cambridge, and for the first five years of his career, he practised general medicine, mainly at Guy’s Hospital and at the Royal Brompton Hospital in London. For a year he ran the intensive therapy unit at Lewisham Hospital, which he believes served him well for a career in rheumatology as it involves treating many systemic diseases.

‘I think it was a great help,’ he recollects. ‘I was lucky that I did a great deal of medicine, so I had experienced nearly all the specialties.’

Rheumatology appealed to him because of all the unanswered questions. ‘Compared to other specialties, you had so much freedom to do things because it was a relatively new speciality, and no one had devised protocols or algorithms of how to treat things. You could look at everything from afresh and first principles,’ he says. 

After two years in Australia as head of rheumatology at the Walter and Eliza Hall Institute and a consultancy post at the Royal Melbourne Hospital, he returned to the UK in 1987 to become a senior lecturer at the University of Birmingham. Here, he began his research into early intervention and began to make waves in rheumatology, which would fundamentally change how the disease is treated and understood.

Prevention of disability through research

Professor Emery says his ‘obsession’ was to treat patients before they developed a disability. ‘Our mission statement was actually prevention of disability through research,’ he says.

To improve patients’ lives and treat early, the referral system for RA required a huge overhaul. Professor Emery set to work in Birmingham. Every three months, he would write to over one thousand GPs to convince them to refer RA patients earlier so the disease could be prevented or at least held back. Usually, patients with inflammatory arthritis would only see a specialist after suffering for years with the disease, and by this point, there was much less that could be done to help them.

‘There was this huge inertia initially. It was very difficult to convince GPs it was worth referring patients urgently to a rheumatologist because they just thought rheumatologists can’t really diagnose them. And even if they can, they can’t treat them, so what’s the point of urgent referral,’ Professor Emery recalls.

Today, clinicians around the world use a standard clinical assessment developed by Professor Emery and his team to refer RA patients at the earliest stage possible. At specialist early arthritis clinics, patients are then assessed and, where appropriate, biomarkers are used to predict how their condition will develop.

Imaging innovations in RA

Early intervention was, in part, made possible by the development and advancement of imaging techniques. With his colleagues in Leeds, Professor Emery set out to make imaging part of the RA treatment pathway. And, despite being told by ultrasound (US) manufacturers that there was no future for musculoskeletal ultrasound, he persisted.

‘They couldn’t see what it was going to do,’ he says. ‘They hadn’t spoken to anyone who was trying to treat or cure rheumatoid arthritis.’

Professor Emery eventually persuaded an American company to give him a machine, which he brought back to the UK and began researching the use of US in RA.

As he anticipated, US and magnetic resonance imaging (MRI) proved to be much more sensitive than conventional X-rays since clinicians can non-invasively detect any swelling inside the joint, something Professor Emery notes is incredibly difficult to do without imaging at an early stage of disease. X-rays measure structural changes as a result of past inflammation, whereas US and MRI measure both structural damage and current inflammation. Thus, X-rays are historical whereas US and MRI are predictive of the future, he says.

After leading a targeted US initiative (TUI) in 43 countries, ultrasound is now routinely used in most arthritis clinics around the world to predict patient outcomes. Professor Emery and his team have also introduced MRI to examine bone abnormalities alongside ultrasound imaging for tissues.

‘These imaging modalities are diagnostic at the start of the disease,’ he says. ‘They’re used for assessment and MRI in particular can be used for understanding pathogenesis. If you find subclinical synovitis on ultrasound or MRI, you can tell which [patients] will progress.’

Remission as the outcome of choice

Early diagnosis and aggressive treatment of the disease meant that, for the first time, the disease could be put into remission with a complete suppression of synovial and systemic inflammation. This turned treatment on its head. In the past the aim had been to simply treat symptoms as they emerged to reduce or manage pain.

The Leeds-based research team led the first international trials of anti-TNF therapy using monoclonal antibodies with very early disease and showed that biologic therapy could induce remission in patients. Professor Emery’s research has resulted in remission being accepted as the outcome of choice for patients with an early diagnosis.

One of his biggest challenges today is not getting enough patients into long-term remission and not targeting the patients in most need in the early stages of RA, despite the research providing evidence of best practice.

‘We still don’t see patients early enough, and we’re not allowed by NICE to necessarily use the best drugs at the earliest moment,’ he says. He believes 70-90% of RA patients could be put into long-term remission from the current research findings. A RCT of personalised medicine with biologiscs has just been completed at Leeds, which hopefully influence this issue, he says.

Working collaboratively with different specialties has been essential in both Professor Emery’s research and clinical work. In his clinics, he works with neurologists, immunologists, respiratory physicians, renal pysicians, cardiologists and dermatologists and he’s the first to admit that this multidisciplinary approach has enhanced his practice. ‘I’ve learned more from other specialties than I do from my own speciality, and I think they do as well,’ he says.

Professor Emery hopes his continued research will move the field even further, and he’s keen to work with colleagues in other specialities to support this. He finds running research ideas by them particularly beneficial.

The road to RA prevention

In the last decade it has been realised that RA is the end point of a continuum. RA patients go through a ‘pre-clinical’ phase characterised by autoimmunity, with or without subclinical joint and systemic inflammation, and thus, RA is initially a systemic disease. Furthermore, the first musculoskeletal involvement frequently is not the joint but the tendon and, specifically, peritendon of the interossei.

For the last 17 years Leeds has run a national study of individuals at risk of RA. ‘We’ve developed, probably, the most definitive risk score, so we can very accurately tell GPs which at-risk patients to refer,’ Professor Emery explains. ‘We’ve got very accurate predictors now of not only who will get rheumatoid arthritis, but when.’

The Leeds team is currently involved in a prevention study examining how a patient’s gene expression affects the efficacy of medications. The next steps, Professor Emery says, will be to identify those with gene expression abnormalities and tie them to a specific drug, identifying individual groups of patients for particular treatment regimens.

Prevention of RA is the ultimate goal. ‘We don’t cure the patients, we don’t prevent it – or we haven’t until now,’ he says. ‘I never thought we’d get to prevention. That’s what I wanted to do the first day I saw a rheumatoid patient, to try and prevent it, and that was a long, long time ago. It’s only now that people are waking up to the fact that this is possible, and I think in the next few years it’ll become a routine process.’