Team: RheumaNavigators

Base article:  Rivellese F, Nerviani A, Giorli G, Warren L, Jaworska E, Bombardieri M, Lewis MJ, Humby F, Pratt AG, Filer A, Gendi N, Cauli A, Choy E, McInnes I, Durez P, Edwards CJ, Buch MH, Gremese E, Taylor PC, Ng N, Cañete JD, Raizada S, McKay ND, Jadon D, Sainaghi PP, Stratton R, Ehrenstein MR, Ho P, Pereira JP, Dasgupta B, Gorman C, Galloway J, Chinoy H, van der Heijde D, Sasieni P, Barton A, Pitzalis C; STRAP collaborative group. Stratification of biological therapies by pathobiology in biologic-naive patients with rheumatoid arthritis (STRAP and STRAP-EU): two parallel, open-label, biopsy-driven, randomised trials. Lancet Rheumatol. 2023 Nov;5(11):e648-e659. doi: 10.1016/S2665-9913(23)00241-2. PMID: 38251532.

Authors: EMEUNET

1. Yvonne Tan, BSc, MD, MSc, Clinical Research Fellow, University of Manchester, United Kingdom, Clinical research fellow
2. Jean-Guillaume Letarouilly, MD, PhD, Service de rhumatologie, CHU Lille, Univ. Lille, Lille, France, Attending
3. Guillermo Carvajal Alegria, MD, PhD, Department of Rheumatology, Tours University Hospital, Tours University, Tours, France, Associate Professor
4. Milena Bond, Department of Rheumatology, Teaching Hospital of the Paracelsus Medical University, Hospital of Bruneck  (ASAAA-SABES), Bruneck, Italy, PhD candidate.
5. Francesca Crisafulli, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili  of Brescia, University of Brescia, Brescia, Italy, Attending
6. Magda Osipyan, Department of Rheumatology, Vardanants Medical Center, Yeveran, Armenia, Associate Professor
7. Alejandro Gomez Gomez, MD, PhD, Department of Rheumatology, Hospital Universitari Vall d’Hebron, Barcelona, Spain, Attending
8. Krystel Aouad, MD, MSc, MPH, Department of Rheumatology, Saint George Hospital University Medical Center, Saint George University of Beirut, Lebanon, Assistant Professor

Team Overview: 

The STRAP trial is like setting sail with a “golden compass” to navigate the uncharted waters of rheumatoid arthritis (RA) treatment, with personalized medicine as the ultimate destination. A total of 223 RA patients across 26 centres in the UK and Europe embarked on this quest, none having previously used biological therapies. Each patient underwent a “mystical” synovial biopsy to reveal their B cell type—either “B cell-poor” or “B cell-rich”—intended to serve as a guiding light.

Three biological “armors”—rituximab, etanercept, and tocilizumab—were chosen as companions, each patient randomly assigned to one. The hope? That this “golden compass” of B cell types would direct researchers to the ideal treatment for each patient. However, the journey proved more complex than anticipated. After 16 weeks, the B cell profiles did not reveal the anticipated answers. Rituximab was not the “guiding star” as there was no difference in ACR 20 response (primary endpoint) compared with the other two “armors”: tocilizumab or etanercept. Yet, the “golden compass” provided valuable information as there was a lower response to rituximab in patients with a “pauci-immune” (low immune cell) profile, and B cell-rich patients treated with rituximab faced an increased risk of joint damage.

Yet, there was a silver lining: all three treatments held steady in terms of safety, acting like steadfast allies in Lyra’s world and protecting patients equally well across B cell profiles. Although the STRAP trial did not provide a definitive answer, it became a compass pointing researchers toward deeper questions in RA treatment. The journey to precision medicine continues, with the “golden compass” guiding the way through RA’s vast, uncharted landscape and setting the course for future discovery. The compass is set, and the adventure awaits.

Related content on theMednet.org:

Does synovial biopsy provide diagnostic value in undifferentiated inflammatory arthritis?

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