Autoimmune Rheumatic Diseases are a group of disorders where the immune system malfunctions and attacks the person's own tissues.
Throughout this century there have been major advances in our understanding of the pathophysiological basis of the Rheumatic diseases.
Most of these discoveries have underscored the importance of immune response in the aetiology of such diseases.
In some cases, significant strides in delineating the immunopathological basis of diseases such as Rheumatoid Arthritis have provided a blue print for defining mechanisms of action of present therapeutic agents as well as a paradigm for the development of newer therapies.
Advances in molecular biology have led to development of biologic therapies which have revolutionized the therapeutic approach of chronic inflammatory Rheumatic diseases, particularly in patients resistant to standard treatment.
Their use has indeed allowed for a better prognosis, also leading to clinical remission in some patients.
In Rheumatoid Arthritis, well established biologics, such as anti- TNF blockers, have extensive data on safety and efficiency. The long term experience of the use of these biologic agents in real life clinical settings has increased the confidence of patients and clinicians in their benefits.
The lack of direct comparison between the effectiveness of different TNF inhibitors or their safety profile make the decision of choosing a certain anti TNF agent instead of another quite difficult to justify.
The therapeutic armamentarium for RA is continuously expanding. In addition to TNF inhibitors, other biologic agents have been shown as effective in treatment of patients with RA, providing opportunities for better disease control in patients who had an unmet need through lack or loss of response to conventional DMARDs or TNF blockage, or intolerance to these therapies.
The various clinical and laboratory abnormalities associated with SLE need tailored therapeutic interventions.
Despite the large number of biologic treatments with potential efficacy for controlling different aspects of lupus disease, it is worth mentioning that only one biologic treatments, Belimumab, was proven effective in large phase III clinical trials leading to the licensing of a new therapy for Lupus.
Rituximab is widely acknowledged as effective in treating refractory SLE.
Although biologic therapies have transformed management of many autoimmune Rheumatic conditions, their efficacy in treatment of SSc so far has been disappointing. This likely reflects the pathophysiological complexity of the disease and wide variability in presentation .
New treatment options are being explored and improved knowledge about the disease has led to better disease monitoring, earlier detection of organ complication & resulting overall better survival among patients with the more sever diffuse subset of SSc.
Number of biologic treatments for PsA increased significantly in recent years. Also the small molecule inhibitors might be the next treatments licensed for PsA.
Anti TNF therapy has been a major advances in the management of SPA. Anti TNF agents are useful in controlling the symptoms of SPA; however there is debate whether they prevent structural damage.
Most patients benefit from ant TNF therapy, but some lose the efficacy with time and some fail to respond.
There has been advancement in therapy in the management of SPA with new agents. IL 17 blockade is another major therapeutics target in axial SPA.
Understanding the role of B cells activity in the pathophysiology of AAV has created a clinical need for more targeted treatment, which should also aim to minimize toxicity.
Currently, rituximab is the best studied B cell depleting agent. There is a good quality evidence to support using rituximab for remission induction of AAV, as it appears to be at least as efficacious and as safe as the standard treatment with cyclophosphamide. Moreover in refractory and relapsing patients rituximab was found to be superior to standard treatment.
As our understanding of disease pathogenesis develops and the potential of novel biologic therapies unfolds, more agents are developed in order to target the relevant pathways.
In this review, we have highlighted the most important biological therapies used in treatment of Rheumatic diseases and have explained their mechanism of action and the possible side effects.
We have also talked about new biological treatments recently proved to be used in treatment of Rheumatic diseases and those which are still under trial .