Joint Damage in RA is Down Significantly

I remember when I was a Rheumatology Fellow in the early 2000s, listening to the stories of my mentors about how terrible RA used to be and how the widespread adoption of methotrexate had significantly changed patient outcomes since the late 1980s. Now, as a fellowship program director, I tell similar stories to my trainees: of how newer therapies like the biologics and the adoption of aggressive treat-to-target strategies has all but eliminated the advanced arthritis changes of RA that rheumatologists once routinely encountered. [[{"type":"media","view_mode":"media_crop","fid":"47039","attributes":{"alt":"Christopher Collins, M.D.","class":"media-image media-image-right","id":"media_crop_4472259129968","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5506","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Christopher Collins, M.D.","typeof":"foaf:Image"}}]]

The recent publication by Lewis Carpenter, et al. "Have radiographic progression rates in early rheumatoid arthritis changed? A systematic review and meta-analysis of long-term cohorts," in the March 8 online edition of Rheumatology, seems to confirm what we have been seeing in our clinics: that joint damage in RA is significantly decreasing. When compared to pre 1990, the last 25 years has noted a drop in joint damage by about 50 percent. The investigators found that the annual rate of progression of structural joint damage was significantly lower in patients treated after 1990 (0.68% vs 1.50%; P < 0.05), which the authors attribute to "critical changes in treatment practices over the last three decades." 

With more aggressive therapy, especially in early disease, I have personally found myself referring fewer and fewer patients for joint replacement surgery, and have not seen near the degree of “classic” RA damage in the hands and feet my patients. It should be noted that this remarkable achievement has not been cheap. According to the CDC, in 2003 the total cost attributed to arthritis and other rheumatic conditions in the United States was $128 billion, an increase from $86.2 billion in 1997. (2010 costs not yet available, but will likely be even higher).

However, I am hopeful for two things in the future which might help contain some of these costs. First, is that we should about now start observing the financial effects of fewer joint replacement surgeries and all of its associated expenses. This phenomenon may very well help offset some costs of our more  expensive therapeutics in upcoming analysis. The second is the impending arrival of biosimilars (and in the distant future, small-molecule generics) which will hopefully start to drive down the price tag of these very expensive medications.

References:

Lewis Carpenter, Elena Nikiphorou, et. al. "Have radiographic progression rates in early rheumatoid arthritis changed? A systematic review and meta-analysis of long-term cohorts," Rheumatology. doi: 10.1093/rheumatology/kew004. First published online: March 8, 2016