Gaining Control of RA Sooner Rather than Later Best for Joints

Persistent moderate disease activity can cause long-term joint damage in rheumatoid arthritis patients, shows a study published in the Annals of the Rheumatic Diseases.

The study, published online March 15, is based on the data analysis of 2,045 patients in Great Britain over a 25-year period.

“This illustrates the far from benign consequences of persistent moderate disease activity, and supports European League against Rheumatism treat-to-target recommendations to secure low disease activity or remission in all patients,” write the authors who were led by Dr. Elena Nikiphorou of the Whittington Hospital in London.

In treating rheumatoid arthritis, physicians now generally adopt a treat-to-target treatment approach - which is largely considered a standard of good practice in the U.S. and abroad. It can lead to remission more quickly or low disease activity and possibly prevent further joint damage. [[{"type":"media","view_mode":"media_crop","fid":"46921","attributes":{"alt":"©ImagePointFr/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_4655478110585","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5483","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":"©ImagePointFr/Shutterstock.com","typeof":"foaf:Image"}}]]

The two patient databases used in the study:  the Early Rheumatoid Arthritis Study (ERAS) of patients with early RA (<2 years disease duration, no prior csDMARD) who were treated between 1986 and 1999 at hospitals in England. And, the Early RA Network (ERAN) of early RA patients (<3 years disease duration) from 23 centers in England, Wales and Ireland between 2002–2012.

Disease activity was defined by a mean disease activity score (DAS28) of between one and five years.; remission (RDAS≤2.6), low disease (LDAS>2.6–3.2), low-moderate (LMDAS≥3.2–4.19), high-moderate (HMDAS 4.2–5.1) and high (HDAS>5.1).

“Patients in the RDAS category had no HAQ progression, demonstrating that functional preservation is achievable; as embodied in the T2T principles. While predictably patients in the HDAS category showed the highest functional limitation and progression, those in the LMDAS and HMDAS categories also demonstrated significantly greater progression than the RDAS category, illustrating that these are not benign states,” the authors wrote.

Patients with low-moderate (LMDAS) and high-moderate (HMDAS) had a significantly higher prevalence of major surgery compared with those in remission (RDAS) and high-moderate  patients with intermediate surgery showing the consequences of sustained moderate (mDAS) and csDMARD therapy between one and five years.

“These findings highlight the long-term health burden in patients with RA not achieving early and sustained remission,” the authors wrote.

Patients in remission did not show additional signs of disability after five years, but there was a significant relationship between rising DAS28 and disability scores (Health Assessment Questionnaire (HAQ)) at one year. In 27,986 person-years follow-up, 392 intermediate and 591 major surgeries occurred.

There was no significant difference in HAQ progression or orthopedic episodes between remission and low-disease categories.

In ERAS, csDMARD use was mainly sequential monotherapy. In ERAN, more frequent and earlier use of combination csDMARD therapies and in a small proportion bDMARDs (<2% by 1 year, <10% by 3 years) were employed.

“Our findings demonstrate an association between increasing disease activity, measured by mean DAS28 after csDMARD initiation, and functional limitation, measured by absolute HAQ scores and the rate of progression of HAQ over 5 years,” the authors wrote.

References:

Elena Nikiphorou, Sam Norton, et al. "Association between rheumatoid arthritis disease activity, progression of functional limitation and long-term risk of orthopaedic surgery: combined analysis of two prospective cohorts supports EULAR treat to target DAS threshold," online March 15, 2016. Annals of the Rheumatic Diseases. doi:10.1136/annrheumdis-2015-208669