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Initial combination therapy has been shown to be superior to step-up combination therapy in groups of RA patients; however, these findings are difficult to reconcile with the observation that many RA patients will have complete remission of disease on methotrexate alone. Practice patterns tend to emphasize initial treatment with methotrexate monotherapy, followed by the addition of other agents in combination for those with inadequate responses.
Antibodies against citrullinated proteins have emerged as powerful diagnostic and prognostic tools in RA that may contribute to the initiation phases of the disease. The enzymes that catalyze the citrullination process, known as peptidyl argenine deiminases (or PADs), may also be involved in the initiation and propagation steps of the RA disease process. Additionally, autoimmunity to these catalysts may identify a subset of RA patients with unique disease phenotypes.
The T-cell inhibitor efalizumab (Raptiva) has demonstrated efficacy in the treatment of moderate to severe plaque psoriasis. However, it has not demonstrated efficacy for the treatment of psoriatic arthritis and, in one study, was associated with worsening of arthritis symptoms. Only a minority of individuals with psoriasis have a concomitant inflammatory arthritis, making therapy with efalizumab an option for the treatment of a large number of psoriasis patients who have no articular involvement.
Knuckle Cracking Q&A from Johns Hopkins Arthritis Center