Patients With Rheumatoid Arthritis Not Switching Treatments to Hit Low-Disease Activity Target

Jeffrey R. Curtis, MD, MPH

Although patients with rheumatoid arthritis are recommended for routine measurement of disease activity and the adjustment of drug therapy in order to reach remission or low-disease activity by both American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR), new data presented at the 2018 ACR/ARHP Annual Meeting, October 19-24, 2018, in Chicago, Illinois, shows that the treatment regimens for many patients are not being changed to reach a “treat-to-target” goal for low disease activity.

In order to identify longitudinal rheumatoid arthritis treatment changes and the disease activity metrics used to measure these changes, investigators from the University of Alabama at Birmingham (UAB) utilized data from the ACR’s national, qualified clinical data registry, Rheumatology Informatics System for Effectiveness (RISE). From 2016 registry data, investigators identified adult patients with rheumatoid arthritis who had 1 or more visits with their rheumatologist with an available disease activity measure (eg, RAPID3, CDAI). This was determined to be the index visit.

For each patient evaluated, disease activity measurement(s) were assessed, and investigators calculated the proportion of patients with moderate/high disease activity at the index visit. At the follow-up visit—which occurred 7 to 12 months after the index visit—treatment and disease activity were evaluated, and the results were stratified based on available measurement tools and patients’ baseline rheumatoid arthritis medications.

Approximately 50,996 of the 457,950 patients with rheumatoid arthritis included in the 2016 RISE registry were identified as eligible. A total of 76.7% of eligible patients were women, 52.8% had Medicare insurance, and 25.3% had concurrent glucocorticoid use. The mean age was 62.4 (standard deviation: 13.7).

At the index visit, most patients (85%) were evaluated with only 1 rheumatoid arthritis measurement. “RAPID3 was most commonly used (79%),” according to a statement on the study, “followed by CDAI (34%) and DAS 28 ESR/CRP (3%). A total of 7467 (14.6%) patients had both RAPID3 and CDAI measured at the index visit.”

Between 36.6% and 58.4% of patients with moderate or high disease activity did not change treatments over the course of the year following the index visit. The results indicated that those patients who were taking combination therapy with methotrexate and a biologic were “the least likely to change treatments.” Furthermore, the study results indicated that “of 2433 patients with persistent moderate or high disease activity measured by CDAI at 2 or more consecutive visits, the proportion of treatment switching was similarly low.”

According to Jeffrey Curtis, MD, MPH, MS, the data indicate that for patients with rheumatoid arthritis and moderate or high disease activity, about one- to two-thirds of the time, treatment is not accelerated as it should be.

"We need to be a) identifying and addressing barriers to rheumatoid arthritis treatment acceleration, and b) engaging patients much more effectively in goal setting for their arthritis care," Curtis said in an interview with MD Magazine®. "In rheumatology, both providers and patients have too often accepted ‘it’s good enough’ in terms of rheumatoid arthritis disease control, but that’s far from ideal. Nobody going to an oncologist says, ‘Just make my tumor smaller.’ They say, ‘I want to be in remission.’ We need to bring that type of expectation, and those conversations, into rheumatology for rheumatoid arthritis-related care."

When patients with rheumatoid arthritis did change therapy, their disease activity improved.

“With this analysis, we are in the process of understanding some of the factors associated with (failure to) accelerate treatment,” Curtis added. “The next logical steps would be to design intervention(s) focused at providers, health care systems, and patients to motivate appropriate rheumatoid arthritis treatment acceleration and improve outcomes.”