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MANY RA PATIENTS DO NOT SWITCH THERAPIES DESPITE NOT MEETING A LOW DISEASE-ACTIVITY TARGET
Newswise — CHICAGO – Nearly half of adult rheumatoid arthritis patients in a national registry did not change their current treatment over the next year to reach a “treat-to-target” goal for low disease activity, according to new research findings presented this week at the 2018 ACR/ARHP Annual Meeting (Abstract #2856).
Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints in the hands and feet are most commonly affected. Sometimes RA can affect your organs, such as eyes, skin or lungs. About 75 percent of RA patients are women.
Both the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) recommend routine measurement of RA disease activity and the adjustment of drug therapy in patients to attain remission or low-disease activity. It is unclear whether or not this approach is used in real-world settings. Researchers at the University of Alabama at Birmingham (UAB) conducted a study to identify longitudinal RA treatment changes and the disease activity metrics used to measure these changes using data from the ACR’s national, qualified clinical data registry, Rheumatology Informatics System for Effectiveness (RISE).
“The main impetus for the study was to understand whether rheumatologists who routinely say that they follow treat-to-target guidelines and strive for low disease activity and remission for most or all their RA patients, are indeed doing so,” said Jeffrey R. Curtis, MD, MPH, Marguerite Jones Harbert and Gene Ball Endowed Professor of Medicine at UAB, and the study’s co-author. “The concern was for clinical inertia: the idea that patients may not be doing well, but treatment is not being changed to try and improve disease control. Because this would reflect a quality of care gap where guidelines are not being followed, we wanted to understand the real-world experience of what was happening in clinical practice.”
The UAB researchers identified 50,996 patients in RISE who met the study’s inclusion criteria: an adult RA patient who had one or more rheumatologist visits with an available disease activity measure (such as RAPID3 or CDAI) in 2016. The researchers assessed which disease activity measurements were used by the rheumatology provider to assess each patient, and then found the subgroup of patients with moderate or high disease activity. They evaluated treatment and disease activity changes at follow-up visits occurring up to 12 months later. Results were stratified based on which disease activity measurement tool was used (RAPID3 vs. CDAI), starting disease activity (moderate/high vs. low/remission), and baseline RA medications used. They conducted subgroup analyses for patients with repeated visits where they were in persistent M/HAD and based on other factors.
A majority of patients with any disease activity measurement available was evaluated with the RAPID3 (79 percent), followed by the CDAI (34 percent). For patients with moderate or high disease activity, 36.6 percent to 58.4 percent did not change RA treatments over the next year. The range reflected their background treatments--those on combo therapy with methotrexate and a biologic were the least likely to change treatments. Of 2,433 patients with persistent moderate or high disease activity measured by CDAI at two or more consecutive visits, the proportion of treatment switching was similarly low.
When the RAPID3 and the CDAI were discordant (moderate/high by RAPID3, low/remission by CDAI), treatment switching was approximately two-fold less likely than when they were concordant (both were moderate/high). When patients did change treatments, disease activity improved as expected.
“These findings shine a spotlight on the relatively high proportion of patients who fail to change RA therapies despite not achieving the treat-to-target goals of low disease activity or remission,” said Dr. Curtis. “While a number of explanations might be offered, including limitations of the current RA measurement tools, and some patients being on maximal medical therapy (for example, methotrexate, biologics or low-dose glucocorticoids), this finding is concerning. It suggests that multi-touch, multi-modal interventions are needed to encourage clinicians and patients to strive to improve RA disease control and use the available RA therapies in a more aggressive fashion, thereby leading to better outcomes.”
While the data in this study was supported by RISE, the views expressed in the study represent those of the authors, not necessarily those of the ACR.
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About the ACR/ARHP Annual Meeting
The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. With more than 450 sessions and thousands of abstracts, if offers a superior combination of basic science, clinical science, tech-med courses, career enhancement education and interactive discussions on improving patient care. For more information about the meeting, visit https://www.rheumatology.org/Annual-Meeting, or join the conversation on Twitter by following the official #ACR18 hashtag.
About the American College of Rheumatology
The American College of Rheumatology is an international medical society representing over 9,400 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit www.rheumatology.org.
Abstract #: 2856
Do Patients with Moderate or High Disease Activity Escalate RA Therapy According to Treat-to-Target Principles? Results from the ACR’s RISE Registry
Huifeng Yun1, Lang Chen1, Fenglong Xie1, Himanshu Patel2, Natalie Boytsov2, Xiang Zhang2 and Jeffrey R. Curtis1, 1University of Alabama at Birmingham, Birmingham, AL, 2Eli Lilly and Company, Indianapolis, IN
Background/Purpose: Routine measurement of RA disease activity and adjustment of drug therapy to attain remission or low disease activity is recommended by the ACR and EULAR. However, it is unclear whether this occurs in real-world settings. We identified longitudinal RA treatment changes stratified by disease activity categories and the methods used to measure it.
Methods: Using the ACR’s national EHR-based RISE registry, we identified adult RA patients who had ≥ 1 rheumatologist visit (index visit) with a disease activity measure available (e.g. RAPID3, CDAI) in 2016. We assessed disease activity measurement(s) used for each patient and calculated the proportion of patients with moderate/high disease activity (M/HDA) at the index visit. We evaluated treatment and disease activity changes at the follow-up visit occurring month 7-12 after index. Results were stratified based on available measurement tool and patients’ baseline RA medications. Subgroup analyses were conducted for patients with ‘persistent’ M/HDA (at both the index visit and the visit immediately prior), for patients with past (ever) biologic use, for patients with seropositive RA, and for those with past methotrexate use.
Results: Among 457,950 patients included in the 2016 RISE registry, we identified 50,996 eligible RA patients. Mean age was 62.4 (SD: 13.7); 76.7% were women; 52.8% had Medicare insurance and 25.3% had concurrent glucocorticoid use. Most (85%) were evaluated with only one RA measurement at the index visit. RAPID3 was most commonly used (79%), followed by CDAI (34%) and DAS 28 ESR/CRP (3%). A total of 7,467 (14.6%) patients had both RAPID3 and CDAI measured at the index visit. For patients with M/HDA and RA medication at the index visit and who had a follow-up visit occurring 7-12 months after index (n=2,336 for RAPID3, n=904 for CDAI), changes in treatment is shown (Figure). Irrespective of baseline RA medication, RA treatment change did not exceed 65% of the patients. For the subgroup of patients with persistent M/HDA by RAPID3 (n=1,241) or CDAI (n=497), the proportion of treatment switching was consistent with the main analysis. Patients with any history of biologic exposure had a similar pattern in therapy change (<10% different). The treatment pattern for seropositive patients and with a history of methotrexate was also similar to the main analysis.
Conclusion: Irrespective of the measurement tool used (RAPID3 or CDAI), past biologic use, or persistent M/HDA, almost half of RA patients in the ACR RISE registry with M/HDA did not change their current therapy over the next year. To optimize RA therapies in accordance with treat-to-target principles, more effective intervention is needed to encourage treatment change and improve patient outcomes.
Disclaimer: This data was supported by the ACR’s RISE Registry. However, the views expressed represent those of the authors, not necessarily those of the ACR.
Disclosures: H. Yun, Bristol Myers Squibb, 2 L. Chen, None. F. Xie, None. H. Patel, Lilly, 3 N. Boytsov, Lilly, 3 X. Zhang, Lilly, 3 J. R. Curtis, Amgen Inc., 2, 5, AbbVie Inc., 2, 5, BMS, 2, 5, Corrona, LLC, 2, 5, Janssen, 2, 5, Eli Lilly, 2, 5, Myriad, 2, 5, Pfizer, Inc., 2, 5, Roche/Genentech, 2, 5, Radius, 2, 5, UCB, Inc., 2, 5
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