"Patients with rheumatoid arthritis differ by age, duration of illness, accompanying disease, self-injection capability, risk factor for complications, and economic status. Therefore, drug selection considering an individual's condition is crucial."

Rheumatoid arthritis is caused by abnormally activated immune cells attacking joints, thereby inducing inflammation and pain. If not treated early, repeated inflammation over time could result in joint deformities and loss of function.

Along with improved disease awareness, physicians are provided with more treatment options that they can use. For example, Janus Kinase (JAK) inhibitors brought a paradigm shift to rheumatoid arthritis treatment.

Professor Hae-Rim Kim, the Department of Rheumatology at Konkuk University School of Medicine, assessed that oral JAK inhibitors substantially helped solve unmet needs in clinical fields.

Recently, JAK inhibitors have been used as a vital treatment option for patients with rheumatoid arthritis and ankylosing spondylitis.

Kim explained, "Rheumatoid arthritis occurs when autoimmune reactions cause inflammation in the thin tissue lining of joints. As a result, damages to cartilages and bones surrounding the joints lead to loss of joint function, causing permanent dysfunctions." Kim added, "JAK inhibitors that can be orally administered and have almost similar effects now enable patients to manage arthritis effectively."

However, concerns for 'safety' were raised after JAK inhibitors were reported to come with adverse cardiovascular events in 2021.

At that time, the U.S. Food and Drug Administration (FDA) cautioned that JAK inhibitors have the risk of cardiac disorders and cancer. The Ministry of Food and Drug Safety (MFDS) in South Korea also distributed safety documents. Ultimately, the U.S. FDA decided to add a new black box warning to JAK inhibitors, citing major adverse cardiovascular events (MACE), thrombosis, and death.

Although a causal association between the drug and adverse reactions has not been demonstrated, the safety issue of JAK inhibitors has not bee resolved. Because of this, warnings have been issued to clinical practices.

Regarding this matter, Kim emphasized the individualized treatment regimem to consider each patient's condition. This means that the selection of drugs cosidering an individual's condition is crucial.

Kim said, "For patients who are at high risks, such as those who are seniors, have tumors, or have cardiovascular diseases, drugs with different mechanisms of actions is considered first ahead of the use of JAK inhibitors," and added, "Because JAK inhibitors could increase the risk for infections, especially shingles, various immunizations are recommended to prevent such infections before the use of the drug. Vaccines for pneumonia, shingles, and influenza could be considered, and patients with latent tuberculosis must undergo prior treatment."

"Special exemption of calculation provisions must be improved for rheumatoid arthritis"

When asked if there could be system-wise improvements, Kim mentioned a 'special exemption of calculation provisions' of the National Health Insurance system.

Rheumatoid arthritis is caused by autoimmune reactions of immune cells against specific proteins in the body. It is known that rheumatoid factor and anti-CCP antibodies are the leading causes of the disease.

Rheumatoid factor or anti-CCP antibodies are found in 70-80% of all patients with rheumatoid arthritis. The remaining patients who do not have those factors are categorized as seropositive and seronegative rheumatoid arthritis.

Previous studies have shown that seropositive rheumatoid arthritis patients tend to have more severe disease and poorer prognosis compared to seronegative patients. As a result, when 'special exemption of calculation provisions' was implemented, only seropositive patients received the benefits.

In other words, seronegative patients, nearly 20% of all patients with rheumatoid arthritis, do not benefit from 'special exemption of calculation provisions.'

Kim said, "Unfortunately, approximately 20% of rheumatoid arthritis patients are excluded from receiving 'special exemption of calculation provisions' for severe diseases because they test negative for rheumatoid factor and anti-CCP antibodies. As a result, the treatment costs a lot." Kim added, "There should be systemic improvements to ensure these patients are also included in the special provisions."

"Currently, biological agents and targeted synthetic anti-rheumatic drugs can only be used at least six months after the first-line treatment, which limits the ability to provide early and aggressive treatment," Kim added. "There is a need to ease the reimbursement criteria for drug use based on physicians' clinical decisions."

Lastly, Kim emphasized the importance of early diagnosis of rheumatoid arthritis and complications management.

Kim explained, "Big differences in prognosis are reported between patients who dive into treatment after early diagnosis and those who have delayed diagnosis and treatments over two years. Individuals who have experienced unexplained small joint swelling and pain over six months are recommended to see physicians," and added, "The most common cause of death of patients with rheumatoid arthritis is surprisingly cardiovascular disease. Assessment of the risk of disease-related complications and an appropriate treatment addressing these risks are important."

Lastly, Kim advised, "Patients who receive treatment earlier have a good prognosis, and drugs with different mechanisms of action are currently available, as well as drugs under development," and added, "Patients who are diagnosed with rheumatoid arthritis do not need to be afraid nor be disappointed, and I wish the best for patients to live healthy lives by seeking treatments proactively."