The use of precision medicine may revolutionize the management of rheumatoid arthritis (RA). By combining insights from synovial biopsy findings with artificial intelligence analysis of blood work, precision medicine is allowing for more personalized care that can encompass the management of not only the patient’s inflammatory symptoms but also pain from other sources that may be resistant to traditional therapies.

Precision medicine with respect to RA is really about 2 things. The first involves selecting the right treatment based on the patient’s phenotype, and we have been doing this for a long time. This is not really practicing precision medicine, but it is practicing focused, personalized medicine. For example, if there are multiple therapies that I could give to an individual patient, but I do not have good comparative data showing that 1 drug is clearly better than another, I will ask about the patient’s issues, symptoms, comorbidities, and preferences to better select a therapy.

The second thing that we are talking about with precision medicine involves analyzing the results of a patient’s synovial biopsy to help sort out symptoms that are not being addressed by their current therapy. This idea is similar to what oncologists have been doing for a while in that they no longer choose treatments based on the organ in which the cancer occurs; they choose treatments based on what a biopsy reveals about the cancer cell and its genetics. Similarly, in precision rheumatology, I can get a biopsy of the synovial tissue to gain insights into which of the available drugs is most likely to work for my patient with RA. Additionally, for someone with RA who has ongoing symptoms, a synovial biopsy may enable me to gain insights into whether switching therapies may or may not be beneficial. The hope is that we will learn from the results of the biopsy and then also look to the results of the patient’s blood work or other biomarkers for more information.

People have been studying the blood of patients with RA for years, but TNF or IL-6 levels in the blood do not really help us decide what to do in terms of treatment. However, if we are able to learn something from the synovial tissue, then maybe we can correlate those findings with something in the blood that we did not recognize before. That is where artificial intelligence and machine learning may come into play, because you are basically taking data and identifying patterns that show up. These types of data can also be obtained using smartphones or wearable technologies that track disease throughout the day.

Finally, you should not simply be looking for inflammatory cytokines in blood, as many patients with RA also experience significant noninflammatory pain. If a patient with RA remains symptomatic while on biologic therapy, it is important to ask the following: What is it that is refractory? Is the patient refractory because of an inflammatory disease process that is not responding to treatment, or are their refractory symptoms coming from something else that is noninflammatory? In the case of the latter, switching biologics may not help. If there are other elements at work, then you have to approach the patient differently, which can be difficult to sort through.