INTRODUCTION
This free CME activity is based on a dinner meeting titled "Optimizing Remission in Rheumatoid Arthritis: A Disease Management Case-based Approach" taped in Chicago, Illinois, on September 26, 2006. Persons in attendance at the dinner meeting are NOT eligible for AMA PRA Category 1 Credit™ for completing this enduring material. The Discovery Institute of Medical Education (DIME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. DIME designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™.

Please note that the course is accredited only for physicians (MD, DO, or equivalent). All other participants receive a certificate of completion.

Rheumatoid arthritis (RA) is an incurable chronic autoimmune disorder that affects approximately 1-2% of people worldwide. RA can result in progressive joint destruction, deformity, and death. More than 9 million physician visits and 250,000 hospitalizations occur each year because of RA. Despite therapeutic guideline revisions and new treatment options, RA continues to impact societal health and individual well-being.

While pain control and prevention of joint damage and functional loss remain the goals of RA management, earlier intervention with more aggressive therapies is more successful than delayed therapy in altering disease outcome. Historically, pharmacologic and nonpharmacologic approaches were palliative and geared toward maintaining quality of life. The current American College of Rheumatology (ACR) Guidelines algorithm calls for establishing the RA diagnosis early and initiating disease-modifying antirheumatic drug (DMARD) therapy within 3 months. Newer approved therapies target RA proinflammatory cytokines, specifically tumor necrosis factor (TNF) and interleukin 1 (IL-1). Despite aggressive therapy with multiple DMARDs (classic and biologic), 30-40% of patients with RA who receive anti-TNF drugs do not benefit sufficiently from this treatment. These patients may respond to therapies that work through different pharmacologic mechanisms.

Costimulatory modulators represent a new class of emerging biologic therapies that target T-cell activation, as opposed to TNF or IL-1. Two large phase 3 clinical trials of a novel costimulatory modulator have demonstrated the safety and efficacy of biologic therapies, including an ACR20 response of 50.4% in TNF antagonist–refractory RA patients with long-standing, very active disease and significant functional limitations. Selective costimulation modulators may provide hope to patients whose conditions have failed to respond to the heretofore most advanced and effective RA therapies.