RA: Early To Treat, Have Symptoms Beat

Early rheumatoid arthritis treatment and DMARD therapy can lead to remission

(RxWiki News) In the past, doctors started rheumatoid arthritis treatment with medications that mainly dealt with symptoms. Now, doctors start with medications that attack the disease itself, a tactic confirmed once again by a new study.

Previous research has shown that early treatment of rheumatoid arthritis (RA), particularly with a specific type of medication, can put the disease in remission (little to no disease activity).

In a recent study, researchers wanted to see if early rheumatoid arthritis treatment led to the best outcomes in a real world, clinical setting.

The researchers found that patients who were treated within the first 12 weeks of displaying symptoms were more likely to achieve remission than those who were treated later.

Remission was also more likely among patients who were treated with disease-modifying antirheumatic drugs (DMARDs) within the first three months of their RA diagnosis.

"Start your rheumatoid arthritis treatment as soon as possible."

The aim of this study — conducted by Gianfranco Ferraccioli, MD, of Catholic University of the Sacred Heart in Rome, Italy, and colleagues — was to see if early treatment of rheumatoid arthritis could lead to remission, and if remission depended more on the type of treatment or how long patients had had the disease.

Rather than recruiting participants for a controlled study, the researchers studied patients in a real world setting. The participants were drawn from three early arthritis clinics. One clinic represented a small province, another represented a medium sized province and third represented a large metropolitan area.

The study included 1,795 patients with early arthritis, meaning they had had symptoms for 12 months or less. Of these patients, 711 (39.6 percent) had been diagnosed with rheumatoid arthritis. 

Remission was defined as a score of less than 2.6 on the DAS28, which stands for "disease activity score in 28 joints."

DAS28 is a measure of rheumatoid arthritis disease activity that counts the number of tender or swollen joints out of a total of 28 joints. DAS28 scores range from 0 to 10. While a score below 2.6 is typically considered to be remission, a score above 5.1 is considered high disease activity.

Study results showed two factors that best predicted remission of rheumatoid arthritis: having symptoms for less than 12 weeks and being on DMARD treatment within the first three months of a rheumatoid arthritis diagnosis.

Compared to patients who started treatment later, those who started treatment within the first 12 weeks had 2.02 times the odds of achieving remission.

Patients who started DMARD treatment by the third month of disease onset had 1.65 times the odds of reaching remission, compared to those who started taking DMARDs later.

Results also showed that anti-tumor necrosis factor (TNF) medications were given to only 10 percent of patients who started treatment within 12 weeks of having developed symptoms, compared to 32.2 percent of those who started treatment later.

Anti-TNF medications are a newer class of medications given to rheumatoid arthritis patients who do not respond to DMARDs or who experience side effects from DMARDs. The finding that anti-TNF therapy was less common among those receiving early treatment suggests that patients benefited from DMARDs and did not need further therapy with anti-TNF medications.

Overall, 34.3 percent of the patients in this study achieved remission — a rate similar to that found in one previous clinical trial but lower than others, the researchers wrote.

The researchers noted, however, that these previous studies were randomized controlled trials. The current study, on the other hand, was an observational study in which there was more freedom in the choice of treatment, which means it "...may better reflect what happens in the real world of clinical practice," the authors wrote.

"Our observational study in a real-life setting allowed us to draw a clear-cut conclusion. The most important result is that the percentage of patients...that can achieve remission is really high now," they wrote.

They continued that patients being within the first 12 weeks of symptoms "...seems to represent a real window of opportunity, not only in terms of clinical outcomes but also in terms of pharmacoeconomy." 

In other words, starting treatment within the first 12 weeks could have a positive effect on costs for treatment.

"In fact," the authors wrote, "we observed that patients [in the first 12 weeks of symptoms] achieved remission with a significantly lesser use of anti-TNF drugs compared with rheumatoid arthritis patients with a symptom duration of more than 3 months." 

According to the authors, this finding could lead to cost savings, since early treatment may reduce the need for more long-term medications.

Anti-TNF medications can be very expensive. According to the American College of Rheumatology, they can cost more than $10,000 per year. Since DMARDs come in generic form, they can cost much less, even as little as a few hundred dollars per year. Most healthcare insurance plans are likely to cover both types of medications.

Jason Poquette, BPharm, RPh, a registered pharmacist, explained the role of early treatment in rheumatoid arthritis to dailyRx News. 

"Early diagnosis and treatment of rheumatoid arthritis allows us to utilize safer and less costly treatments to help manage a patient’s condition and delay the need for more aggressive therapies," said Poquette, who was not involved in the study. "The early course of treatment, from a pharmacological perspective, generally includes the use of NSAIDs (like ibuprofen, naproxen or piroxicam) and short-term oral corticosteroids like prednisone. These are often effective in reducing the symptoms of joint pain and discomfort, allowing patients to maintain their activities of daily living at home and work.

"However, slowing down the disease progression has become equally, if not more, important when treating RA. Therefore the use of DMARDs (disease modifying anti-rheumatic drugs) such as methotrexate, hydroxychloroquine and others is also becoming an important treatment option early on in therapy. These approaches tend to precede the use of the biologic drugs and TNF inhibitors,” he said.

In closing, Dr. Ferraccioli and colleagues wrote, "The take-home message that arises remains: diagnose early and treat to target within 12 weeks from symptom onset. The recommendation of the European League Against Rheumatism committee stating that 'Patients presenting with arthritis of more than one joint should be referred to a rheumatologist, ideally within 6 weeks after the onset of symptoms' remains of fundamental importance and appears to be increasingly supported by evidence-based data."

The study authors concluded that early referral to a specialist and involvement of all parties (i.e., patients, doctors and health systems) is of the utmost importance to make sure rheumatoid arthritis patients are treated in a timely fashion.

This study was published May 30 by the Annals of the Rheumatic Diseases.

The research was supported by the Italian Ministry of Health. The authors declared no competing interests.

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Review Date: 
June 2, 2013