Preferences of patients and at risk individuals for preventive approaches to rheumatoid arthritis

Effective treatments for rheumatoid arthritis (RA) are available and can lead to remission for some patients but most patients remain on potentially toxic and expensive medications in the long term. Interest is increasingly turning to the disease phases preceding the development of RA that represent opportunities for preventive interventions. ‘At risk’ target populations include individuals with genetic and environmental risk factors, those who have developed systemic autoimmunity, and those who have developed clinically suspect symptoms (e.g. arthralgias without synovitis, or an early arthritis).

Ongoing prospective studies will inform the development of increasingly accurate predictive tools to identify individuals at risk of developing RA. Furthermore a range of preventive approaches have been suggested, including lifestyle modification (e.g. smoking cessation) and pharmacological interventions (e.g. hydroxychloroquine, methotrexate, abatacept, rituximab) that are currently the subject of randomised controlled trials.

As prediction and prevention of RA evolve, it is increasingly likely that those at risk (including asymptomatic individuals) may be faced with complex decisions about whether to accept assessment of their risk status or to take a preventive intervention associated with risk of serious adverse events and uncertain benefit. Acceptance of preventive medication in other contexts can be low. For example, less than 25% of women at high risk for breast cancer are willing to take preventive hormonal treatments. Actual uptake is lower still.

Patients’ beliefs and preferences predict treatment uptake and adherence. Before the dream of preventing RA can become reality, healthcare providers need to understand the perspectives of individuals in the target population, to identify barriers and facilitators for this approach. This commentary will review what is currently known about the perspectives of patients and individuals at risk about predictive and preventive approaches for RA and identify gaps to be addressed to inform the development of efficient preventive strategies.