International Journal of Rheumatic Diseases 2013; 16: 615

LETTER FROM THE EDITOR-IN-CHIEF

Next generation evidence-based medicine: individualised, personalised and humanised

The philosophy of “Publish or Perish” does not generate good science. It does not require a maverick mind to denounce this school of thought. The sole purpose of this concept is often to produce papers desperately for career enhancements and not for benefitting the society with fruits of science. The huge funds required for conducting relevant research including clinical trials often preclude investigator initiated studies. Industry and other vested interests often control and dictate science to their advantage. Less fortunate, poorly -resourced scientists and busy clinicians, especially in developing nations, are forced to carry out poorly designed retrospective studies. The pressure is felt even more if research methodologies are not taught in medical curriculum to create scientific temper and zeal for research resulting in irrelevant and poorly designed studies. A research question should always include a clause “if the research will benefit the mankind in an economic manner?” Practice of evidence-based medicine (EBM) is undergoing its own natural evolution. EBM has come a long way starting from large series and case control studies to observational and cohort studies, from randomized control trials to meta-analysis and still evolving. Technology driven basic science research has strengthened biological understanding of diseases. While genetic variation of an individual including pharmacogenetic factors may eventually be the deciding factors in choosing the right therapeutic agent, it remains costly and elusive at the moment and in its rudimentary phase too. Nevertheless, the concept of Personalised and individualized medicine has come to stay. Technological advancements are marching faster than ever before. Technologically sophisticated choices are expected to be within reach of all sections of society in the future. Any new venture of research in that direction should also keep the social commitments and economic considerations

in mind, so that the benefits of advanced medicine do not become prerogatives of privileged few. In other words, such futuristic medicine, or if one can call it “Next generation EBM”, should be humanized and not just personalized or individualized. Prescribing TNF blocker or triple DMARD or IL-6 inhibitor or rituximab or any other agent singly or in combination to an RA patient then will not be a trial and error subjecting the patient to cost, toxicity and inefficacy. This reality is still evolving, but comparative effectiveness trials (CET) with large sample size in populous nations may be good economic alternatives to RCT to generate evidence for resource limited set up. A landmark study of this kind is the 2012 CET with triple DMARD therapy in RA showing benefit comparable or superior to biological agents.1 This year several RCTs have proven this point beyond doubt. Similarly, large series as observational, case control or cohort studies also contribute to evidence, though not as strong as RCTs or meta-analysis. Relevant research questions can be answered by sound methodology in economical and humane manner in large cohorts to benefit the less advantaged societies till next generation EBM is readily and economically available. Neither present day EBM or nor next Generation EBM will succeed, if not humanized. Happy 2014. Debashish DANDA

REFERENCE 1 Moreland LW, O’Dell JR, Paulus HE et al. (2012) A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: the Treatment of Early Aggressive Rheumatoid Arthritis trial. Arthritis Rheum 64, 2824–35.

© 2013 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd