Harvard Health AdWatch: An arthritis ad in 4 parts

Perhaps you've grown as weary as I have of repeated arthritis ads. They appear in frequent rotation on television, online, and in magazines, promoting Enbrel, Humira, Otezla, Xeljanz, and others.

If you've actually read or listened to these ads, you might have felt perplexed at certain points. Here's a quick rundown on what they're saying — and not saying — in one of those ads.

"The clock is ticking"

Part 1: A teakettle whistles on the stove and a disembodied voice speaks as the ad for Humira opens. "This is your wakeup call. If you have moderate to severe rheumatoid arthritis, month after month the clock is ticking on irreversible joint damage. Ongoing pain and stiffness are signs of joint erosion." Three people are shown starting their day in pain: one rubs his knee and grimaces, another has a sore shoulder, and the third, sore hands. Their suffering is clear, and you hear ticking in the background as a digital clock clicks forward one minute.

Part 2: "Humira can help stop the clock." A garage door opens and out comes the man with the achy knee, now smiling and comfortably walking out into the sunshine as the music swells. "Prescribed for 15 years, Humira targets and blocks a source of inflammation that contributes to joint pain and irreversible damage."

Part 3: The long list of side effects is voiced while happy scenes and beautiful music distract you: an adorable dog hikes with its once-achy-kneed owner; a young mother drops off her kids with a beaming grandma who previously was wringing her sore hands. "Humira can lower your ability to fight infection. Serious and fatal infections including tuberculosis and cancers, including lymphoma, have happened, as have blood, liver, and nervous system problems, serious allergic reactions, and new or worsening heart failure. Tell your doctor if you've been to areas where certain fungal infections are common, and if you've had tuberculosis, hepatitis B, are prone to infections, or have flulike symptoms or sores. Don't start Humira if you have an infection."

Part 4: The big finish is short and to the point: "Help stop the clock on irreversible joint damage. Talk to your rheumatologist."

What did the ad get right?

Let's start with several accurate points:

• The prolonged morning stiffness depicted at the start is a typical symptom of rheumatoid arthritis (RA). It's so characteristic that it helps doctors make the diagnosis.
• Humira is a brand name of adalimumab, a treatment for rheumatoid arthritis and related conditions. It's often highly effective and has a good safety profile, despite the long disclaimer about side effects.
• The drug targets inflammation. It does this by blocking tumor necrosis factor (TNF), a substance directly involved in rheumatoid arthritis inflammation. Anti-TNF drugs were first approved by the FDA for rheumatoid arthritis more than 20 years ago. They have revolutionized treatment for this disease.
• An active lifestyle is a reality for many people with rheumatoid arthritis who begin effective treatment soon after symptoms begin. The potential for improvement is often underestimated, perhaps because it wasn't long ago that doctors had few effective options to treat rheumatoid arthritis. Fortunately, that has changed.

Now, about the rest of the ad

• Ongoing pain and stiffness are not specific signs of joint erosion. They are symptoms of joint inflammation, which may, over time, lead to erosions. However, not everyone with RA experiences joint erosions, and it generally takes many weeks or months for erosions to develop. Showing a clock with minutes ticking by implies more urgency than is accurate.
• The word "irreversible" is stated three times in this 60-second ad. While it's true that joint damage related to RA generally does not heal, some people have minimal or no damage, especially when taking effective treatment. The implication that permanent joint damage is inevitable seems overly dramatic to me, and perhaps alarmist.
• The FDA requires that long disclaimer. While it lists the most important risks and side effects of the drug, some of its equivocal language is chosen carefully: "Serious and fatal infections… and cancers… have happened." Were these problems caused by adalimumab? Or were they unrelated? Or do they just not know? Generally, the safety profile of anti-TNF drugs is considered good. The most recent studies suggest that there is no significant increased risk of cancer, except for skin cancers.
• I would bet that the average person seeing this ad has no idea if they've been in places where "certain fungal infections are common" — or what that even means! In fact, it refers to certain infections that can become silent in the body, but re-activate in people taking adalimumab. This includes histoplasmosis (Midwest of the US), Coccidioides (southwestern US), and blastomycosis (Ohio and Mississippi River Valleys and the Great Lakes).

What's left unsaid?

The ad never mentions some important information about adalimumab:

• It's expensive. While insurance may cover most or all of the cost, the price of adalimumab can run about $40,000/year.
• It's given by injection under the skin (a bit like insulin injections for people with diabetes), usually every two weeks.
• Humira is only approved — and likely to work — for a few arthritic conditions, including RA. It's not for osteoarthritis, the most common type of arthritis, an age-related, degenerative joint disease.
• Four other medications work in a similar way, with similar effectiveness and similar cost, side effects, and risks. Additionally, a host of other medications unrelated to TNF inhibition are also just as effective.

The bottom line

As drug ads go, those for arthritis in general and adalimumab in particular are not the worst I've seen. But they can be misleading, perplexing, and incomplete. Of course, the main purpose of these ads is to sell drugs, not to provide a complete and balanced review of treatment options for RA. You'll need to ask your doctor for that.

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