Review: Arthritis Without Pain

Arthritis Without Pain: The Miracle of TNF Blockers
by Scott J. Zashin, M.D. with M. Laurette Hesser
Rev. ed. Sarah Allison Publishing Company, 2004. Softcover, xiv + 261 pp. ISBN 0-9754060-0-0

Of the new TNF-alpha antagonists -- principally etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira) -- that have generated so much attention in recent years and that have promised a revolution in the treatment of arthritic conditions, three things can be said. One, they're extremely expensive, costing thousands if not tens of thousands of dollars a year to administer. Two, they've been the subject of an intense marketing and media campaign on their behalf by the pharmaceutical companies, by doctors, and by advocates, who want as many people taking these new treatments and as many prescription drug plans covering them as possible. And three, from all accounts, they really do work.

The cost makes me blench, and the marketing makes me nervous. But there's a rationale behind both, and that is that these treatments are unlike anything else that we've taken before. They are far more complex to manufacture than traditional drugs, and they cannot be taken orally -- the digestive system would destroy the proteins before they hit the bloodstream -- and so must be administered by infusion or injection. They are, in other words, qualitatively different from any other arthritis treatment out there, and considerable explanation is therefore required.

There is therefore ample justification for a book such as Arthritis Without Pain: The Miracle of TNF Blockers, written by rheumatologist Scott J. Zashin with M. Laurette Hesser. While it suffers from the breathless "miracle-cure" rhetoric that I've seen before and that sets off my internal alarms, it does a respectable job of explaining what these treatments are, how they work, and how they fit in with other arthritis treatments out there. The detail is considerable, from how these treatments are administered, to how long they may take to take effect. And, to be sure, their potential side effects and drawbacks are mentioned as well.

Arthritis Without Pain was first published in 2000; this is the revised 2004 edition. But events have already overtaken things somewhat: Enbrel and Humira have since been approved for ankylosing spondylitis, for example. And it's primarily a book for people with rheumatoid arthritis; those of us with other rheumatic conditions for which these treatments are (now) indicated may be a little disappointed with that focus.

Another shortcoming too obvious to me as a copyeditor, but that most of you couldn't care less about: the book could frankly have been better written and better proofread. (Page 6: "More than 23 million Americans have [osteoarthritis]. Over one-third are women." Why that's more significant than the nearly two-thirds that are, presumably, men I have no idea.)

And is it truly necessary to use the ® symbol in every instance of a trade name? Style guides would not indicate so. But the fact that Zashin and Hessler cannot talk about Enbrel and Remicade, but only Enbrel® and Remicade®, may have something to do with the fact that Zashin has worked as a paid consultant for the companies involved. I would be more comfortable with reports about TNF antagonists that came from sources not so closely affiliated with the companies who made them.

PEI lags in drug approvals

The Arthritis Society is campaigning to raise the profile of arthritis patients during the upcoming provincial election in Prince Edward Island. Notably, they point to how long it takes the provincial drug plan to approve drugs: approvals for biologics lag behind other provinces, and even Celebrex isn't covered. Don't miss the boneheaded responses from the provincial parties that sidestep the question and talk about disease prevention and lifestyle choices: when you've got an inflammatory autoimmune disease, it's already too late for that, and you don't catch what we have from eating too many Ding-Dongs, you assclowns.

Enbrel auto-injector available in Canada

An auto-injector for Enbrel (etanercept) is now available in Canada, which should make it easier for patients to administer their own meds. As someone averse to needles, I can appreciate this.

British Columbia and Remicade

British Columbia's provincial drug plan doesn't cover Remicade (infliximab) for ankylosing spondylitis, though it's been approved for rheumatoid arthritis and Crohn's disease, reports The Peace Arch News, leaving AS sufferers (or, presumably, their private plans) to pick up the full $24,000 tab if they want the newer treatment.

One interesting bit from the article encapsulates the problem with B.C.'s prescription drug coverage: "B.C. pays more for generic drugs than other provinces; and, B.C. is usually last to approve new medications. One drug, Enbrel, for the treatment of psoriatic arthritis, has been under study and review here for more than three years. Meanwhile, it’s approved for use in every other province except Prince Edward Island." Of course, Enbrel (etanercept) is of interest to AS sufferers too.

Anti-TNF treatments and ankylosis

Anti-TNF therapy has been shown to do a good job reducing inflammation, but joint inflammation is only one aspect of our disease. What about ankylosis -- joint fusion? A recent study using tests on lab mice suggests that anti-TNF treatments aren't as effective:

Their findings [...] cast doubts on the feasibility of preventing joint and spine ankylosis with anti-TNF strategies while shedding light on the process of SpA. [...]

For the mice with induced arthritis, etanercept had a significant impact on disease severity, inhibiting inflammation and cartilage and bone destruction. For the mice with spontaneous arthritis, however, etanercept proved no more effective than placebo at inhibiting new cartilage or bone formation or ankylosis. [...]

"Our observations strengthen our hypothesis that new bone formation in SpA is clinically relevant and largely independent of inflammation," Dr. Luyten states. "Long-term results from clinical trials are required to corroborate this hypothesis in patients with SpA," he acknowledges, "and to define whether the process of ankylosis should become a separate therapeutic target."

Long-term results for Enbrel and AS

Pharmaceutical company Amgen announced long-term results for Enbrel (etanercept): after three years, they report, 59 patients in their clinical trial "experienced sustained improvement in signs and symptoms, spinal mobility and physical function." Of that 59, 46 experienced at least 20 per cent improvement, and 18 achieved partial remission. Business Week; press release (reprinted here and here).

It's interesting to see longer-term data on the new anti-TNF treatments, especially in the context of some anecdotal reports of them not working for people after a while.