October 24, 2019
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Many patients with RA fail to modify treatment despite high disease activity

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Approximately one-third to two-thirds of patients with rheumatoid arthritis fail to alter their treatment even when experiencing moderate to high disease activity, according to data published in Arthritis Care & Research.

“Rheumatologists might be reluctant to modify RA treatment care depending on which measurement tool is being used for disease activity assessment, as their confidence in the various tools available to assess active inflammatory disease might vary,” Huifeng Yun, PhD, of the University of Alabama at Birmingham, and colleagues wrote. “For example, tools that contain more physician-derived elements (eg, tender and swollen joint count, as in the CDAI and DAS28) may be felt to be more ‘objective’ in the mind of clinicians.”

“The patient’s background RA treatment may also play a role in this decision-making process,” they added. “For example, among patients who are already treated with a biologic in combination with one or more conventional synthetic disease modifying antirheumatic drugs plus pain medications and glucocorticoids, a partial response to this treatment regimen might be satisfactory enough to continue without modification. Because there is some potential for at least short-term clinical worsening if the biologic was discontinued and another was started, both patients and clinicians may be reticent to switch treatments.”

To find which measurement tools rheumatologists use in practice to assess patients with RA, and analyze treatment use and changes in relation to disease activity, as well as determine how different tools impact treatment changes, Yun and colleagues conducted a retrospective study of data from the American College of Rheumatology’s RISE registry. According to the researchers, RISE is a national registry that collects data from electronic health records at participating rheumatology practices.

Image of arthritic hand 
Approximately one-third to two-thirds of patients with RA fail to alter their treatment even when experiencing moderate to high disease activity, according to data.
Source: Adobe

Focusing on data from January 2016 to June 2017, the researchers identified 50,996 patients aged 18 years or older who had been diagnosed with RA and had at least two RISE-documented visits, as well as at least one disease activity measure reported in 2016. When limited to patients with at least one follow-up visit after the index date, a cohort of 27,274 were eligible for the longitudinal analysis. Yun and colleagues classified the patients’ index visit treatment as either combination or monotherapy, with conventional synthetic and biologic DMARDs. The primary outcome was any treatment change in conventional synthetic and biologic DMARDs between the index date and follow-up visit.

According to the researchers, the most common measure was RAPID3, which was used with 78.9% of patients, followed by CDAI, with 34.2%. The frequency of treatment change during followup was ranged from 35.6% to 54.6%, including patients with moderate-to-high disease activity as measured by RAPID3 or CDAI. Patients aged 75 years or older (adjusted OR = 0.63; 95% CI, 0.5-0.78) and those already receiving combination therapy with conventional synthetic DMARDs (aOR = 0.45; 95% CI, 0.33-0.61), or combination therapy with biologic DMARDs (aOR = 0.3; 95% CI, 0.24-0.38), were less likely to switch treatment. This finding remained accurate after multivariable adjustment.

“We found that one- to two-thirds of patients failed to modify RA treatment, even when they were in moderate/high disease activity,” Yun and colleagues wrote. “Patients on combo [biologic] DMARDs were less likely to switch, which may reflect patients’ and rheumatologists’ risk aversion to stop one biologic in order to start another. Multimodal treat-to-target interventions directed both at patients and providers are needed to encourage shared decision making and goal directed care and to overcome barriers to RA treatment change.” – by Jason Laday

Disclosure: The researchers report that the study protocol was prepared by the University of Alabama at Birmingham and Eli Lilly.