medwireNews: Real-world study findings suggest treatment in response to rheumatoid arthritis (RA) disease activity is not being intensified as frequently as it should, despite the recommended treat-to-target strategy.
Jeffery Curtis (University of Alabama at Birmingham, USA) and colleagues say that “one- to two-thirds of patients failed to modify RA treatment, even when they were in moderate/high disease activity.”
They therefore suggest: “Multimodal treat-to-target interventions directed both at patients and providers are needed to encourage shared decision making and goal directed care and to overcome barriers to RA treatment change.”
In all, 27,274 patients identified using RISE registry data had their disease activity measured using the same measure or measures on at least two occasions through 12 months of follow-up. Routine Assessment of Patient Index Data (RAPID3) was the measure predominantly used, in 78.9% of patients, followed by CDAI in 34.2%. One type of disease activity measure was used in most cases, at 85.0%.
At the index visit, 48.2% of patients were in low disease activity or remission according to RAPID3 and 61.2% according to CDAI, 23.0% had moderate disease activity and 28.9% had high disease activity using RAPID 3, and a corresponding 27.1% and 11.6% using CDAI.
The researchers note that for patients with moderate to high disease activity, the change in treatment during follow-up was relatively low, ranging from 35.6% to 54.6%.
Specifically, 54.6% of 852 patients taking conventional synthetic (cs)DMARDs as monotherapy added or switched to csDMARDs (22.1%) or biologic (b)DMARDs (32.5%) in response to RAPID3 measurement, as did 53.2% of 604 patients taking bDMARDs as monotherapy (26.7 and 26.5%, respectively).
The rate of change was lower for the 218 patients who were taking combination csDMARDs and the 662 taking combination bDMARDs, at 45.6% and 35.6%, respectively.
Curtis et al found that the rates of treatment change were similar when CDAI was used to measure disease severity, being most likely in the 342 patients receiving csDMARD (63.4%) and the 217 patients receiving bDMARDs (60.4%) as monotherapy. For the 88 patients receiving combination csDMARDs and the 257 receiving combination bDMARDs, the rates of treatment change were 51.1% and 41.6%, respectively.
Among patients whose disease activity was measured using both RAPID3 and CDAI, the results were discordant in 28% of patients, highlights the team, and treatment change was less likely in these cases.
“This suggests that clinicians may have greater uncertainty regarding the extent of active inflammation as assessed by the RAPID3, and therefore, less confidence in initiating treatment changes,” say Curtis and colleagues in Arthritis Care & Research.
Further analyses revealed that patients who had recently started an RA drug and had higher disease activity were more likely to change their treatments than other patients.
Curtis and co-authors propose that although the higher frequency of treatment change among patients with high disease activity “could in part reflect channeling of more ill patients to receive combination therapy, it may also reflect reticence by the clinician to potentially have to stop a therapy (e.g. a biologic) in order to substitute another, having the potential for worsening or flare of RA.”
Conversely, treatment change was less likely in patients who were already receiving a combination therapy (either csDMARD or bDMARD), were older (≥75 years), or had Medicare coverage.
“Physicians may be less confident that therapies may have the same benefit in older age patients given a dearth of RA trial data among older individuals,” the team suggests.
By Hannah Kitt
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Arthritis Care Res 2019; doi:10.1002/acr.24083