Background The ultimate goal in the treatment of RA is remission, a realistic target in the short term with the availability of biologic agents. The focus in the last decade has been on the use of intensive combination and biologic therapies early on in the disease process. Inception cohorts with long follow up provide the opportunity to examine details of the beneficial effects of therapeutic improvements on long term outcomes in RA.
Objectives To examine secular treatment trends and their impact on disease activity and structural damage in two early RA cohorts covering the pre and post biologic eras.
Methods Two inception cohorts recruited RA patients prior to DMARD therapy, the Early RA Study (ERAS) recruited from 1986-1999 (n=1465), the Early RA Network (ERAN) from 2002 (n=1236). Standardised clinical, laboratory and x-ray measures were performed yearly in both cohorts. Disease modifying, steroid and biologic therapies reflected conventional practice and guidelines of the time frames examined. Recruitment years were grouped into 6 periods (“1”1986-1989, “2”1990-1991, “3”1992-1994, “4”1995-2001, “5”2002-2005, “6”2006-2011) based on numbers adequate for analysis and corresponding to the gradual shifts in therapeutic practice that took place over this time. Disease parameters measured included DAS, radiographic damage (erosions) and orthopaedic surgery.
Results Treatment trends showed a gradual but definite shift from sequential monotherapy to combination therapies and biologics in later recruitment periods. Graphical representations will show the switch from Sulphasalazine as first DMARD to Methotrexate over the recruitment periods. 1: Methotrexate 1%; Sulsphasalazine 54%; other 45%, compared to recruitment period 6: Methotrexate 70%; Sulphasalazine 23%; other 7%). Median times from first outpatient (OPD) consultation to first DMARD improved from 3 months in the earliest recruitment period to 1 month in the latest recruitment period. Times from onset of RA symptoms to 1st rheumatology OPD consultation varied little at 6 months. Over the last 25 years the proportion of patients on monotherapy and sequential monotherapy decreased significantly (p<0.001), the use of triple therapy increased significantly (p<0.001), whereas the use of 2 DMARD combinations has remained stable (P>0.05) (Figure 1). There was a significant decrease in the proportion of patients with active disease at 3 years (defined as a DAS>5.1) from 1986-1989, compared to 1992-1994 (odds ratio 0.55, 95%CI 0.34-0.89), 1995-2001 (OR 0.33, 95%CI 0.18-0.61), 2002-2005 (OR 0.28, 95%CI 0.17-0.46) and 2006-2011 (OR 0.20, 95%CI 0.11-0.38). A similar trend was seen for both presence of erosions and need for some types of orthopaedic surgery.
Conclusions A gradual shift to more intensive disease-modifying (biologic and non-biologic) therapies in the early years of disease was paralleled by improvements in markers of disease severity and significant declines in measures of structural damage. This study confirms the common perception that more intensive treatment impacts on disease severity and outcomes, but also demonstrates that this impact can be up to 25 years later.
Acknowledgements With thanks to clinicians and nurses from the ERAS & ERAN cohorts.
Disclosure of Interest None Declared
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