Background Evolving pharmacologic treatment in rheumatoid arthritis (RA), including methotrexate (MTX) and biologics, has helped to prevent progression of joint destruction. It is still unclear whether current treatment strategies prevent progression of large joint destruction and what factors can predict progression of large joint destruction. The incidence of joint surgery can reflect the long term clinical outcome of RA patients, and the need for joint surgery is considered a marker of disease severity.
Objectives The aims of this study were to explore the trend in incidence of surgery and to identify the risk factors that predict the need for joint surgery in RA patients treated with biologics based on long term observation in a cohort setting.
Methods A retrospective multicenter study was performed by using Tsurumai Biologics Communication Registry (TBCR), which consisted of patients who were starting biologic treatments and included baseline characteristics. To explore the trend in incidence of surgery among the RA patients treated with biologics, all patients were divided into three groups by the time of initiation of the first biologics (group A: 2003-2005, group B: 2006-2008, group C: 2009-2011). The incident rate of joint surgery was determined by the Kaplan-Meier method. Risk factors for incidence of joint surgery were identified by multivariate logistic regression analysis.
Results Of 2072 RA patients registered in TBCR between 2003 and 2011, 145 patients underwent 206 joint surgeries during treatment with biologics. 62% of the surgeries were joint prosthesis procedures (n=128). They were prescribed etanercept (n=114), infliximab (n=56), tocilizumab (n=15), adalimumab (n=14) or abatacept (n=7) at the time of surgery. Mean time between initiation of first biologics and surgery was 2.1 years. Incidence of surgery for group A, group B and group C were 16%, 9% and 4%, respectively. When the characteristics at initiation of first biologics were compared among three groups, there was a reduction in the disease duration (group A: 11.5, group B: 10.9 and group C: 10.0 years) and the level of DAS28-CRP (group A: 5.5, group B: 4.8 and group C: 4.1) over the study period. Since approval of biologics to treat RA in Japan in 2003, the timing of initiation of biologics has shifted toward earlier stages of RA, and the incidence of joint surgery has decreased. Multivariate logistic regression analysis identified no concomitant MTX use [OR 1.80; 95% CI (1.05–3.11)], age (≥50 years old) [OR 3.99; 95% CI (1.57–10.16)], disease duration (≥3 years) [OR 2.36; 95% CI (1.13–4.89)] and high disease activity (DAS28-CRP>4.1) [OR 2.06; 95% CI (1.1-3.83)] as the independent risk factors for incidence of joint surgery. These results suggested that there was difficulty in aggressive therapy for elderly patients because of their comorbidity and more progressive joint damage due to their pre-existing joint damage from aging.
Conclusions Strict control of arthritis using biologics with concomitant MTX is important for preventing destruction of large joints as well as hand and foot joints. Earlier aggressive intervention should be needed for the prevention of large joint destruction, even in elderly patients who have to be under careful observation.
Disclosure of Interest None Declared