More than half of rheumatoid arthritis patients had persistent moderate-to-high disease activity after six months of treatment with a conventional synthetic disease-modifying anti-rheumatic drug (csDMARD), and less than a third had their therapy escalated, indicating that there is considerable need for a treat-to-target approach to care for these patients, say researchers recently writing in Clinical Rheumatology.
For rheumatoid arthritis patients who have active disease despite initial csDMARD monotherapy, guidelines recommend treatment advancement to a combination of csDMARDs and/or use of biologics or Janus kinase inhibitors until remission-to-low disease activity is achieved. In clinical practice, it is common for patients treated with csDMARDs to remain in a moderate-to-high disease state without such treatment advancement, leading to worse short- and longer-term outcomes, such as increased pain burden, disability and irreversible joint damage.
“This study sought to characterize disease burden among patients with rheumatoid arthritis with moderate-to-high disease activity who received csDMARD monotherapy for at least six months but whose treatment had not been advanced to a biologic or Janus kinase inhibitor,” wrote the authors of the study, led by Leslie R. Harrold, M.D., M.P.H., of the University of Massachusetts Medical School in Worcester.
The retrospective study included 409 rheumatoid arthritis patients (77 percent female, mean age 65.9 years; mean duration of csDMARD therapy 407 days), with moderate-to-high disease activity, enrolled in the US Corrona RA registry from 2014 to 2018 with six months of continuous csDMARD monotherapy, who remained biologic naïve. Disease activity was assessed among patients with a six-month follow-up visit.
Of the patients, 54 percent remained in moderate-to-high disease activity and treatment advancement occurred in 29 percent of patients. Those in moderate-to-high versus remission also had no improvements on multiple specific outcomes such as tender and swollen joint counts, DAS28, and modified Health Assessment Questionnaire (mHAQ) scores.
“A significant increase in mHAQ from 0.49 to 0.54 (p = 0.04) over a six-month period may indicate more rapidly progressing and clinically significant disability in patients who continued with uncontrolled disease,” the authors wrote.
Among patients who had achieved low disease activity by six months, improvements were seen on a wide range of measures, including pain, fatigue, and duration of morning stiffness.
Patients with younger age, shorter rheumatoid arthritis duration, and higher disease activity were more likely to have their medication treatment advanced, which suggests that “potentially more aggressive treatment of disease activity is needed across the whole rheumatoid arthritis population,” the authors wrote.
Since several challenges to implementing the treat-to-target approach to care exist, “physicians should take into consideration patient preferences, quality of life, economic factors, and willingness to take on an increased risk of adverse events when discussing treatment plans with patients with rheumatoid arthritis,” the authors wrote.
The authors suggested that treatment should be re-evaluated after three to six months, and patients who are not responding to treatment should have their dose escalated, switch therapy, or have an additional therapy added to their current regimen.
“Systematically evaluating disease activity and responding with titrating medications is something healthcare providers should consider for patients with rheumatoid arthritis,” the authors wrote.
Leslie R. Harrold, Pankaj A. Patel, Jenny Griffith, et al. “Assessing disease severity in bio-naïve patients with RA on treatment with csDMARDs: insights from the Corrona Registry.” Clinical Rheumatology. October 21, 2019. https://doi.org/10.1007/s10067-019-04727-7