Prevention of rheumatoid arthritis: state-of-the-art and considerations for the design of new trials

Rheumatoid arthritis (RA) is among the most common chronic autoimmune diseases. Since it is well recognised that autoimmune processes may be aberrant long before clinical arthritis first develops, a research focus has shifted to the prearthritis stages of RA, under the hypothesis that these early stages are more amenable to disease-modifying interventions. This article summarises recent results from prevention trials with long-standing follow-up and discusses considerations for designing new secondary prevention trials. One of the lessons learned is that interventions for the development of anticitrullinated protein antibodies (ACPA)-positive and ACPA-negative RA can differ and that current prevention studies are labour-intensive due to long inclusion times and long follow-up periods. Importantly, the recently published European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) risk stratification criteria for the development of RA are valuable for selecting a homogeneous risk population and, consequently, an efficient trial design. Further research is needed to determine the best drug and the optimal endpoint. Through continued research, we hope to be able to set up efficient prevention trials and achieve personalised prevention with the right medication for the right patient at the right time.