Adjustment of disease-modifying antirheumatic drug (DMARD) therapy is not happening quickly enough for a substantial minority of rheumatoid arthritis patients with moderate to high disease activity, according to the findings of a registry study that is the first to evaluate this association.

Investigators led by Yomei Shaw, PhD, a research fellow with the National Data Bank for Rheumatic Diseases, retrospectively analyzed data from 538 patients in the university’s Rheumatoid Arthritis Comparative Effectiveness Research ( RACER ) registry who had moderate to high disease activity. Dr. Shaw conducted the study as a doctoral student in the department of health policy and management at the University of Pittsburgh.

In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target (T2T) guidelines to adjust DMARDs, according to published results (Arthritis Care Res. 2017 Sep 21. doi: 10.1002/acr.23418 ). Such delay was more common for certain groups, including those on biologics and those who had rheumatoid arthritis (RA) for longer.

Compared with peers whose therapy was adjusted sooner, patients with such delayed adjustment were about one-quarter less likely to achieve low disease activity or remission during follow-up.

“The results of our survival analyses suggest that delays in DMARD adjustment of more than 3 months are common among RA patients with [moderate to high disease activity], highlighting an important potential gap in quality of care for these patients,” Dr. Shaw and her colleagues wrote.

They acknowledge that some of the delays in adjustment may have been unavoidable. For example, patients on biologic DMARDs may have needed insurance approval to start a new biologic, and patients with long-standing disease may have had fewer options remaining or symptoms that clinicians attributed to irreversible joint damage.

The study’s findings provide additional evidence of the importance of timely, guideline-adherent DMARD adjustment in reducing the amount of time patients spend in moderate to high disease activity, the investigators further contend.

“Promoting T2T in clinical practice requires coordinated change at the system, rheumatology practice, and individual levels,” such as consistently documenting the treatment target, assessing disease activity at every visit, and mandating a minimum visit frequency, they conclude.

Dr. Shaw and her colleagues studied patients having moderate to high disease activity, defined according to the 28-joint Disease Activity Score with C-reactive protein criteria (score of greater than 3.2).

The investigators reported a median time to adjustment of DMARD therapy of 154 days during 943.5 patient-years of follow-up. These adjustments could be adding, switching, or increasing the dose of a DMARD medication (excluding corticosteroids).

In multivariate analysis, patients had a longer time to DMARD adjustment if they were aged 75 years or older (subdistribution hazard ratio, 0.61; P = .02), had lower baseline disease activity (0.72; P less than .01), had longer duration of rheumatoid arthritis (0.98; P less than .01), or were receiving a biologic DMARD at baseline (0.71; P less than .01).

The median time to achieving low disease activity or remission was 301 days for the entire cohort. Patients had a longer time to achieve this goal if their DMARD therapy was not adjusted within 90 days (hazard ratio, 0.76; P = .01) or if they were African American (0.63; P = .01) or had higher baseline disease activity (0.75; P less than .01). They had a shorter time if they had better mental health (1.01; P = .03) or physical health (1.01; P = .02) as assessed with the 12-item Short Form Health Survey.

One of the study authors received research funding from Genentech and is currently employed by AbbVie. The registry used was funded by the National Institutes of Health and Genentech.


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