Andrew Filer, Professor of Translational Rheumatology at Birmingham, is leading clinical research trials at the Queen Elizabeth Hospital that use a pioneering new ultrasound technique to improve diagnosis and treatment of rheumatoid arthritis.
Rheumatoid arthritis (RA) affects 1% of the UK population and can occur in adults at any age. The pain, stiffness and swelling can be disabling, affecting the ability of those suffering to work and live independently.
While there is no cure for the long-term condition, early diagnosis and giving the right treatment can help reduce inflammation in the affected joints, meaning those living with RA can go long periods between episodes (flare-ups). When flare-ups are not swiftly identified or successfully treated, the build-up of swelling sees inflamed tissue actually burrow into the bone. This is known as erosion into the joint and can lead to permanent damage and pain.
But the Birmingham Early Arthritis Cohort (BEACON) team, led by Professor Andrew Filer (Intercalated BSc Medical Biochemistry, 1992; MBChB Medicine, 1995; PhD Immunology, 2006), is working to discover and improve the tests used to make diagnoses and to predict the course of arthritis from the earliest stages of symptoms, significantly improving outcomes for patients.
Andrew, who has just been appointed as Director of the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, says: ‘The focus of our research is to better understand the fundamental mechanisms of how each disease is working inside the body. Discoveries made within the last five to ten years have dramatically advanced our understanding of arthritis and are helping us to find new treatments.
‘A wide range of medications are available for the treatment of RA and there are considerable differences in responses to each treatment among patients.
‘Predicting treatment response is of great clinical importance and the BEACON cohort is carefully tracking the progress of patients with new onset arthritis over time, linking their progress to scientific analysis of samples that they donate.’
Repurposing technology
One area of research the group is investigating involves the use of ultrasound equipment to assess a patient’s joints, looking for the tell-tale signs of inflammation.
While clinical assessment from doctors typically involves a physical examination of joints and feedback from patients, using ultrasound enables researchers to see much more accurately how many joints are really involved, and how inflamed they are.
A trial using ultrasound identified areas of concern before patients had become aware of them, which in turn meant treatment could begin earlier, helping to delay the onset and severity of RA for those patients.
When it comes to understanding the processes going on inside the joint by taking samples of the joint lining, previously this would need surgeons to use keyhole surgery (arthroscopy), but ultrasound provides a way to miniaturise this procedure.
Andrew explains: ‘Ultrasound allows us to take tiny, pinhead sized samples from the inner lining of the joint through a tiny tube the size of a pencil lead, which is a true game-changer. It is a less invasive process than arthroscopy, which usually requires general anaesthetic to use larger-sized surgical instruments.’
Both diagnosis and treatment
These precise tissue biopsies not only give much greater insight into the development of arthritis but also allow doctors to assess how treatments are working – or not – at the heart of the problem.
‘The new style of samples we can get using ultrasound guidance allow us to use advanced technologies (spatial transcriptomics) to see the true complexity of inflammation in the joint. These show that there are around 80 different cell types in the joint, and we have discovered many more cells than we were previously aware of that drive inflammation in the joint,’ says Andrew.
‘We know that RA inflammation begins to flare when certain groups of cells start to work together. The ultrasound samples can show with great accuracy whether treatments are working or not, just as traditional biopsies are used to decide treatment in other conditions. This is important because currently only 60-70% of patients will respond to treatment and some treatments can cost £10,000 a year.
‘Ultimately, we are aiming to reach a point where patients can receive truly personalised therapy. Ultrasound is helping to develop this at a very fast rate. In fact the only issue is that this work generates an enormous amount of data: we are developing a new type of scientist to analyse such rich data.’