Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement
Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.
Major Improvements in Outcomes of Rheumatoid Arthritis Since the Biologic Era and beyond: An Historical Overview from 1989 until 2008 in a Large Inception Cohort of RA Patients.
Kievit1, Wietske, Fransen2, Jaap, De Waal Malefijt2, Maarten, Den Broeder3, Alfons, van Riel2, Piet
Already since the early 80's there has been a movement towards intensified treatment for RA with an increasing use of methotrexate in higher doses up to 30 mg per week in individual patients and DMARD combination therapy.
We hypothesized that the trend of better RA outcomes precedes the era of biologic response modifiers.
Data available from the period between 1989 and 2008 in the Dutch Nijmegen inception cohort was used, including DAS28, HAQ-DI, X-rays and orthopedic surgery. Patients with RA were regularly assessed at scheduled visits. For each individual patient, the average DAS28 and HAQ-DI scores for each calendar year were calculated. X-rays of hand and feet were taken annually and joint surface destruction was scored according to the Ratingen score (range 0190) (data available until 2003). Population mean DAS28 and HAQ-DI over time were corrected for age, gender, rheumatoid factor and disease duration by means of repeated measures analysis (mixed models). Conditional means of DAS28 and HAQ-DI were plotted by calendar year. Median Ratingen scores were compared between calendar years non-parametrically. Orthopedic surgery was analyzed as incidence rates with 95% confidence limits based on a Poisson distribution. To describe treatment, the percentage of patients being treated with MTX or SASP, a biological response modifier, and the mean MTX dose per year were calculated.
Per 2008, 992 RA patients were included, resulting in 8618 patient years. From 1989 onwards, the percentage of patients being treated with SASP decreased to 18% and the percentage of patients being treated with MTX increased to 62% in 2008. The percentage of patients being treated with a biologic was increased to 22% (166/765) in 2008. The MTX dose increased significantly from a mean dose (sd) of 6.7 (1.3) mg/week with a maximum of 7.5 mg/week in 1989 to a mean dose (sd) of 16.1 (5.5) mg/week with a maximum of 30 mg/week in 2008. The Figure A shows the mean DAS28 per calendar year conditional on disease duration, age, gender and rheumatoid factor. According to the repeated measures analysis the mean DAS28 and HAQ-DI were statistically significant higher (p<0.008) in all years compared to 2008, where mean DAS28 was 3.2 and the mean HAQ-Di was 0.47. Median Ratingen score for patients with 3 years disease duration decreased from 12.5 in 1989 to zero in 2003 Figure B. Analysis of the incidence of orthopedic surgeries showed a trend towards lower rates of orthopedic surgery with non-overlapping 95% confidence intervals in the years 2006, 2007 and 2008 compared to almost all previous years.
The better controlled RA that we show is not only attributable to the introduction of anti-TNF, but also to the DMARDs (and especially MTX) which were largely available before the biologic era. We think that utilization of the available therapies can still be enhanced by tight control strategies.
To cite this abstract, please use the following information:
Kievit, Wietske, Fransen, Jaap, De Waal Malefijt, Maarten, Den Broeder, Alfons, van Riel, Piet; Major Improvements in Outcomes of Rheumatoid Arthritis Since the Biologic Era and beyond: An Historical Overview from 1989 until 2008 in a Large Inception Cohort of RA Patients. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :641