Could we prevent rheumatoid arthritis?

Interviewer: Sam Walter (Interviewer, Ideas Lab)
Guest: Professor Karim Raza
Recorded: 17/07/2014
Broadcast: 01/09/2014

Intro VO: Welcome to the Ideas Lab Predictor Podcast from the University of Birmingham. In each edition we hear from an expert in a different field, who gives us insider information on key trends, upcoming events, and what they think the near future holds.

Sam: We’re here today with Professor Karim Raza who’s a Professor of Clinical Rheumatology at the University of Birmingham and Honorary Consultant at Sandwell and West Birmingham Hospital. So you’re here today to talk to us about your event, ‘Can You Prevent Rheumatoid Arthritis’, at the British Science Festival which is held here at the University of Birmingham in September 2014. So before we go into how to prevent the disease, what is rheumatoid arthritis?

Karim: So rheumatoid arthritis is a common disease, it’s actually much more common I think than many people realise. It affects about 1 in 100 people and it’s a condition, which predominantly affects the joints. It typically affects the small joints of the hands and feet but it can often effect other joints as well, so it often spreads from the joints of the hands and feet to involve the ankles, wrists, knees, elbows, even other larger joints and in patients with rheumatoid arthritis those affected joints become painful, they become swollen, they become stiff, so actually people find it very difficult to use their joints, but importantly the inflammation in the joints over time causes damage and destruction to the joints. So in the long term people’s function at the joint is often poor. The other important thing that actually happens in many patients with rheumatoid is the inflammation that starts off in the joints, often spills out of the joints and affects other areas. So for example it can affect the lungs, making people short of breath, it can affect the heart making people have heart disease early. Often people with rheumatoid arthritis have heart attacks, angina, much earlier than you would necessarily have expected them to have and that’s because of these affects of the joint inflammation spilling out of the joint and affecting other bits of the body. So it’s a common and severe disease and once it’s established, it’s a disease which we can control but we can’t cure and that’s really why there's so much interest in this concept of prevention because actually if all you can do with a chronic disease is to control it with potentially toxic drugs, actually what you’d like to be able to do is stop people from getting the disease in the first place. Now I say we can control it, we can control it in many patients reasonably well. The reason people get rheumatoid arthritis is their immune system starts behaving in an abnormal way and starts attacking their joints, in the same way actually as the immune system of someone with diabetes might attack the pancreas which produces insulin. In patients with rheumatoid, the immune system targets the joint and it causes inflammation and destruction of the joint and so then you can understand that the treatments for people with rheumatoid arthritis is with a range of drugs that targets the immune system and depresses the function of the immune system to stop it attacking the joints and then you realise that we have an immune system for a reason, which is to fight off infection and so if you depress the function of the immune system to try and prevent the arthritis being bad, you potentially put people at risk of side effects and complications of the treatment which include an increased risk of infection.   

Sam: So actually by treating rheumatoid arthritis you can create other problems which weren’t there before the arthritis. 

Karim: That’s the case in many situations where patients and their doctors have to carefully weigh up the risks and the benefits of treatment, but there are no treatments for rheumatoid arthritis that are without risk and some of the risks are quite significant and many of them relate to this risk of infection. And so to try and come up with a strategy where you would prevent people from developing this chronic long term condition and would avoid the need for long term potentially toxic treatment in them, is really something that not only the patients that we look after want on behalf of the rest of the population who haven’t got this condition yet, but actually what we want as well to try and prevent people from developing rheumatoid arthritis.  

Sam: And so in order to do that what are the early signs that people should look out for or that doctors should look out for?

Karim: So the earliest signs of rheumatoid arthritis are pain, stiffness particularly stiffness first thing in the morning, morning stiffness lasting for at least an hour and swelling of the joints of the hands and the feet. That’s usually where it begins, it usually begins on both sides of the body, it’s usually a symmetrical problem and so those are the earliest signs of someone who might be developing rheumatoid and if people develop those kind of signs, then actually they need to be going to see their GP very quickly and we need to be seeing them in hospital very quickly to start treatments for rheumatoid arthritis. And we’ve done a lot of work around those areas in Birmingham trying to understand what’s happening in the joint in the very early stages to see if we can develop designer drugs in those earlier stages to try and control the inflammation. But really a direction of travel of our research and of many people’s research is taking us before those stages, before the stages where people develop even pain and swelling for the first time, to stages where people don’t even know that they’ve got any problems with their joints. They don’t actually have any problems with their joints but we know that they’re at risk of developing rheumatoid arthritis in the future and we’ll talk in a second maybe about how we might know that they’re at risk of developing rheumatoid but we can pull out groups of people who are at high risk of developing rheumatoid arthritis and then so potentially rather than waiting for them to develop pain and swelling and then treating them in a reactive way, we might be able to target them and say ‘look, you’re at high risk of developing this problem in the future. Rather than waiting till you’ve got the problem, why don’t we do something about it now potentially to prevent you developing the problem as we move forward’.

Sam: So the idea of preventative treatment, it’s still something that’s in very early development. 

Karim: That’s absolutely true. It is very much in a developmental stage at the moment. I guess it’s important to think about why people develop rheumatoid arthritis in the first place and in broad terms it’s a combination of having a set of genes that you’ve inherited from your parents that puts you at risk of having rheumatoid arthritis, in combination with being exposed to things in the environment which put you at risk of having rheumatoid arthritis. Now, that being exposed to things in the environment could include being exposed to cigarette smoke which we know is a big risk factor for rheumatoid arthritis; it could include developing certain infections which we think may be risk factors for developing rheumatoid arthritis. In fact, there’s been quite a lot of research to show that if the population stopped smoking, a large number of cases of rheumatoid arthritis would be prevented. In fact about a third, you would prevent about a third of people who would otherwise develop rheumatoid arthritis from stopping developing rheumatoid arthritis, but sometimes it’s not so easy to identify that someone has a modifiable environmental risk factor and then you might want to be thinking about drugs that you could use in people at higher risk to prevent them getting rheumatoid and that’s really where we’re still very much at the research stage. 

Sam: So what area of rheumatoid arthritis is your research focusing in on?

Karim: So my research really focuses in on the very early stages of rheumatoid arthritis, those stages when people first start developing joint pain, first start developing joint swelling, first start developing joint symptoms, within the first few weeks of the onset of symptoms, trying to understand what the processes are that are happening in the joint, how are the immune cells behaving, how are they interacting with other cells in the joint before people have actually developed full blown rheumatoid arthritis, but when they’re at the earliest stages of the disease which may over time lead on to rheumatoid arthritis to see if we can pinpoint things at those early stages which would be more amenable to treatment than at later stages of disease. 

Sam: So what’s the next big stage in the future research of rheumatoid arthritis?

Karim: I think the next really big areas are trying to understand what the best ways of treating people who haven’t yet got rheumatoid arthritis but are at risk of rheumatoid arthritis would be to prevent them from developing the full blown disease. You know, you come to see me with your joints painful and swollen for a few weeks, you haven’t developed full blown rheumatoid arthritis but you’re at risk of it. Now we know if we just left you untreated for months and months and you develop full blown rheumatoid arthritis, then at that stage we could control you but we couldn’t cure you. But there are a number of studies taking place both in the UK and internationally at those very earliest stages before people have developed the problems but when they have the first suggestion that they might be on the road to developing rheumatoid arthritis where people are treated with short courses of treatment to try and switch the inflammation off and the idea of that worked would be that you would avoid someone having to be on lifelong treatment for rheumatoid arthritis but you would have caught something in its earliest stage and prevented the inflammation from progressing. 

Sam: That’s some really exciting research and it’s fantastic that the possibility to treat people before they’ve developed the condition so Professor Karim Raza, thank you very much for joining us today. 

Karim: Thank you.

Outro VO: This podcast and others in the series are available on the Ideas Lab website: There's also information on the free support Ideas Lab has to offer to TV and radio producers, new media producers and journalists. The interviewer and producer for the Ideas Lab Predictor Podcast was Sam Walter.