Background Treatment strategies for rheumatoid arthritis (RA) have changed over the last decades. InSwedenthe recommendation in the 1990s was initial DMARD monotherapy and early use of low-dose glucocorticoid, and “step-up” combination therapy reserved for more severe disease. In 2000 that strategy was changed to possibility to initiate treatment with biologics when the first DMARD or combination of DMARDs failed.
Objectives To compare patient and disease characteristics over the first 5 years of disease in a large inception cohort of early RA patients, included 1992 to 1999 and 2000 to 2006, respectively
Methods In all 2544 RA patients were recruited from the BARFOT prospective multicenter observational study. They had at inclusion a disease duration of ≤12 months. The patients were divided into two groups, group 1 (N=1256, 66% women) included 1992 to 1999 and group 2 (N=1288, 68% women) included 2000 to 2006. Disease Activity Score (DAS28), VAS pain and Health Assessment Questionnaire (HAQ) were assessed at inclusion, 3, 6 months and 1, 2 and 5 years. Remission was defined as DAS28 <2.6. Statistical comparisons between groups were done by Mann-Whitney U test and Chi2.
Results At inclusion, the women in group 2 were, compared with those in group 1, older, mean (SD) 58 (16) vs. 55 (16) years, p<0.001, and more frequently RF positive 65% vs. 57%, p=0.001, whereas the men did not differ in these aspect. In both women and men group 2 had compared with group 1, higher DAS28, 5.42 (1.23) vs. 5.26 (1.23), p=0.004 and 5.28 (1.23) vs. 5.01 (1.27), p=0.001, respectively. VAS pain was also higher in group 2 compared with group1, in women 49.8 (24.2) vs. 46.7 (24.4), p=0.004, and in men trend vise 44.6 (24.6) vs. 41.4 (24.1), 0.075. HAQ did not differ between the groups.
Over time DAS28 decreased in both groups, and as from 6 months in men and 12 months in women the mean DAS28 was significantly lower in group 2 compared with group 1 and remained lower during the entire 5 year follow-up. At 5 year 42% of the women in group 2 were in remission vs. 29% in group 1, p<0.001, and in men the corresponding percentages were 64% and 51%, p=0.006. At 5 year there were also fewer patients with high disease activity in group 2, women 6% vs. 16% and men 4% vs. 8%, p<0.001 and p=0.006, respectively. During follow-up VAS pain and HAQ decreased similarly in the two groups, thus with no differences between groups at any time point.
The patients in group 1 started with methotrexate (MTX) in 21%, with sulphasalazine (SAL)in 29%, and with other DMARDs in 10%, and the corresponding figures for group 2 were 61%, 19% and 3%. At 5 year follow-up patients in group 1 got MTX in 32%, combination therapy in 9% and biologics in 6%, and in group 2 the corresponding figures were 41%, 9% and 20%.
Conclusions Despite having higher disease activity and more pain at disease onset, the RA patients included in the 2000s achieved higher frequency of remission and fewer had high disease activity at the 5 year follow-up compared with those included in the 1990s, a difference suggested to reflect the more active medical treatment. Still 51% were not in remission indicating that there is further need to intensify treatment. Interestingly, however, improvement in pain and HAQ did not differ between the two patient cohorts, why also other mechanisms than inflammation might be of importance.
Disclosure of Interest None Declared
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