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Highlights from

American College of Rheumatology

annual meeting 2018

Chicago, Illinois 19-24 October 2018

Approximately half of RA patients do not have their therapy changed as needed within a year

Take-home messages
  • Between one- and two-thirds of patients with RA and moderate-to-high disease activity do not have their medications changed within a year
  • These results do not reflect ACR/EULAR guidelines
  • Fear of changing medications and older age may contribute towards switch inertia
“More effective intervention is needed to optimise RA therapies in accordance with treat-to-target principles, as well as to encourage treatment change and improve patient outcomes.”

Professor Jeffrey Curtis Professor of Medicine, Division of Clinical Immunology and Rheumatology, University Alabama at Birmingham, US

Almost half of patients with rheumatoid arthritis (RA) with moderate-to-high disease activity did not have their current therapy changed within a year, according to an analysis of data from the American College of Rheumatology (ACR)’s national Rheumatology Informatics System for Effectiveness (RISE) registry.

The data suggest that more effective intervention is needed to optimise RA therapies and improve patient outcomes in accordance with treat-to-target principles. Both routine measurement of RA disease activity, and the adjustment of drug therapy to attain remission or low disease activity, are recommended by both the ACR and the European League Against Rheumatism (EULAR).

Professor Jeffrey Curtis, from the University Alabama at Birmingham, US, presented the analysis of the RISE data at the 2018 ACR/ Association of Rheumatology Health Professionals (ARHP) Annual Meeting.

“More effective intervention is needed to optimise RA therapies in accordance with treat-to-target principles, as well as to encourage treatment change and improve patient outcomes,” Professor Curtis remarked. “How can we help our patients do better? Do rheumatologists practise what they preach in striving to attain low disease activity or remission, as our guidelines suggest? Is this actually happening in the real world?”

He added that the study was designed to reflect a quality-of-care gap where guidelines were not being followed. “In this respect, we wanted to understand the real-world experience of what was happening in clinical practice.”

The RISE registry is based on the concept of a registry that sources all data from rheumatologists’ electronic health records, without extra manual input, explained the professor. “It has existed for several years, and this particular study is one of the larger, nationwide applications that looks at whether patients are having treatment accelerated who are in moderate-to-high disease activity.”

A total of 50,996 eligible adult RA patients were included in the analysis. Patients had attended at least one rheumatologist appointment with a disease activity measure available (eg routine assessment of patient index data 3 (RAPID3), clinical disease activity index (CDAI)) in 2016 and at least 1 year of follow-up to observe any treatment changes. The proportion of patients with moderate-to-high disease activity at the index visit was determined, as well as treatment and disease activity changes at the follow-up visit (usually 7-12 months later).

Results were stratified based on the available measurement tool and patients’ baseline RA therapy. There were a number of subgroup analyses including for patients with ‘persistent’ moderate-to-high disease activity (at both the index visit and the visit immediately prior), for patients who had received a biologic therapy previously, for those with seropositive RA, and for those with past methotrexate use.

Mean age was 62 years, 77% were women, 53% had Medicare insurance and 25% had concurrent glucocorticoid use. Most (85%) were evaluated with only one RA measurement at the index visit.

Regarding disease activity tests, RAPID3 was most commonly used (79% of patients), followed by the CDAI (34%), and disease activity score-28 (DAS28) erythrocyte sedimentation rate/ C-reactive protein (ESR/CRP) (3%). A total of 14.6% of patients had both RAPID3 and CDAI tests at the index visit.

For patients with moderate-to-high disease activity, 36.6% to 58.4% did not change RA treatments over the year following the index visit. The range reflected their background treatments, with those on combination therapy of methotrexate and a biologic, the least likely to change treatments.

Remarking on the main study findings, Professor Curtis said, “In patients with moderate-to-high disease activity for one or multiple visits, between one- and two-thirds of patients did not have any of their treatments switched,” he said, adding that, “guidelines suggest that most of these patients should have their treatments switched so if we are missing between one- and two-thirds of people then we are a long way from the 100% or close to it.”

The study did not seek qualitative data on why this was happening, but Professor Curtis did highlight some possible reasons for the findings. “What background therapy the patient was on was hugely important. If you were not on a biologic or a targeted therapy then about two-thirds of people had their treatment changed, and had one of these drugs added in. People over the age of 75 years were less likely to change therapy, and characteristics of the physician and the practice setting found that some doctors were more aggressive in switching than others.”

“In many cases, doctors weren’t quantifying anything, it was the ‘Hi, how are you feeling, does anything hurt?’ approach and this means that a lot of data are lost because there is nothing quantitative to draw on, and you cannot improve on something that you cannot measure, and there’s a lot of non-measurement going on,” Professor Curtis pointed out.

Furthermore, he said that the data source was able to demonstrate that for those who changed therapy, measureable improvement was demonstrated, adding that the registry was very effective at demonstrating real-world evidence.

Professor Curtis highlighted three implications of the findings. “Firstly, we need to measure things that patients care about. In fact, one of the results showed that treatment changes were more predicated on the doctor’s examination rather than what the patients told them. Patients care less about their joint counts than they do about fatigue and pain, and what affects daily living.”

Secondly, he added that as a field they needed “to better practise what they preached. If we want to get patients into remission or low disease activity then it isn’t happening in between one- and two-thirds of patients. There are some factors like being afraid to change or risk aversion that we could push on. In older patients, doctors might be fearful of changing their treatment but this might not be grounded in reality. Finally, we need more interventions where patients are encouraged to do better. We need to empower patients to be their own advocates.”

Based on Yun H, Chen L et al. Do patients with moderate or high disease activity escalate RA therapy according to treat-to-target principles? Results from the ACR’S RISE registry (abstract 2856). Presented on Tuesday 23 October 2018.

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