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Re: Characteristics of patients with rheumatoid arthritis in Hungary: comparison with the QUEST-RA study

Dear Editor, Sokka et al reported results of a survey of rheumatoid arthritis (RA) patients from 15 countries in 2005-2006, the QUEST-RA study.[1] A similar cross sectional survey was performed in 2004 in Hungary by rheumatologists involving 257 consecutive patients with RA attending routine visits to 6 hospital based outpatient rheumatology centres. Detailed description of the study and certain disease parameters has been published elsewhere.[2] Although our research was not part of the QUEST-RA, it focussed also on quantitative clinical characteristics and drug therapy use of the patients. Therefore, our results can offer some additional information to the QUEST-RA presenting the situation in Hungary. We highlight some methodological issues as well.

Demographic characteristics of our sample was similar to the median QUEST-RA results but functional status was worse at a shorter disease duration and disease activity was higher (DAS28≤3.2: 9%, DAS28>5.1: 48.6%) ranking Hungary to the group of countries with severe disease. Poland’s results were the most similar.(Table 1) Methotrexate was the most frequently ever used DMARD in Hungary likewise in nearly all QUEST-RA countries. Leflunomide was more common in our survey, only France, Spain and Italy had higher rates. Regular reimbursement of the biological drugs was introduced in 2006 in Hungary so thus explains their low rate.

The QUEST-RA presented the delay of the first DMARD in months. Recall bias is suspected in a retrospective survey involving patients with disease duration median 9-13.5 years. Furthermore, calculating the delay based on the start of the first symptoms is very uncertain and difficult to standardise, especially in a retrospective international study. Symptoms to consider (erosions? swollen joints? morning stiffness?) must be very well defined and no literature background for that. Countries with early RA registries (that is not the case of Hungary) are more likely to offer correct information than others wherein inputs are based on patients’ interviews and documentation reviews. Therefore, we asked for the data on a year level and considered the establishment of the diagnosis by ACR criteria. In our survey, the majority (51.3%) of the patients started a DMARD in the year of the diagnosis, mean delay was 1.79(SD3.96) years, which is similar to the QUEST-RA results and 5.3% have already had a DMARD before having established RA.

The rate of patients that has never taken any DMARD is also a relevant aspect. In Hungary, 31(18%) patients have never experienced a DMARD.

The overall drug history of a sample does not necessarily reflect thecurrent therapy use.[3-5] Analysis of current rates (and doses) of DMARDs is essential for the evaluation as these, especially biologicals, can strongly influence the actual clinical status. In Hungary, methotrexate was the most frequently taken DMARD also at the time of the survey (49%) and the rate of leflunomide was still substantial (27.6%), but sulfasalazine and hydroxychloroquin were less used (11.3% and 7.3%, respectively), gold injections decreased robustly (2.7%) and even less patients (0.7%) were just taking biologics.

Our results present the recent past in Hungary, registries are of primary importance to follow up the changes.

References

1. Sokka T, Kautiainen H, Toloza S et al. QUEST-RA: Quantitative clinical assessment of patients with rheumatoid arthritis seen in standardrheumatology care in 15 countries. Ann Rheum Dis Published Online First: 5 April 2007. doi: 10.1136/ard.2006.069252.

2. Péntek M, Kobelt G, Czirjak L et al. Costs of RA in Hungary. J Rheumatol 2007;34:1437-8.

3. Jobanputra P, Wilson J, Douglas K et al. A survey of British rheumatologists’ DMARD preferences for rheumatoid arthritis. Rheumatology 2004;43:206-210.

4. Edwards CJ, Arden NK, Fisher D et al. The changing-use of disease-modifying anti-rheumatc drugs in individuals with rheumatoid arthritis from the United Kingdom General Practice Research Database. Rheumatology 2005;44:1394-1398.

5. Le Loet X, Berthelot JM, Cantragel A et al. Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology. Ann Rheum Dis 2006;65:45-50.

Table 1 Clinical characteristics and drug therapy use in Hungary (year 2004) in comparison with results of a survey performed in 15 countries (years 2005-2006), one of them is Poland.