Background Delay of disease modifying anti-rheumatic drugs (DMARDs) therapy is an important factor for poor outcome in rheumatoid arthritis (RA).
Objectives To study the lag time between the onset of arthritis symptoms and the beginning of DMARD's therapy, and to determine factors associated with therapy delay.
Methods We studied 70 consecutive patients with new RA onset (70% female, median age 60±14 years) admitted to the Department of Internal Medicine and Rheumatology, Military Institute of Medicine in Warsaw. Demographic, clinical, laboratory, and treatment variables were collected. Disease activity was assessed every month during the first year of therapy using DAS28, CDAI, SDAI indices. Health assessment questionnaire (HAQ) and Beck depression inventory were assessed at baseline, after 6 and 12 months. Factors associated with delay of DMARD's therapy were analyzed.
Results The median time from the onset of symptoms to DMARD administration was 3 months (0.5-36 months).The median time before the patient was assessed in primary care was 3 weeks (7 days-35 months),the median time to referral from primary to secondary care was 1 month (0 days-30 months)and the median delay from that referral to the assessment by rheumatologist was 10 days (0 days-3 months). 33 (47.14%) patients were diagnosed within 3 months, 15 (21.4%) within 6 months, 22 (31.4%) waited for diagnosis >6 months. These 22 patients were significantly older than others. ESR, global visual analogue scale (VAS) by patient and physician, CDAI, SDAI, DAS28, HAQ at baseline correlated inversely with the treatment delay. The treatment delay was significantly longer in patients living alone. This delay was determined by the period from symptoms onset to primary care visit and the time from secondary care referral to rheumatologist's consultation (p=0.006). The treatment delay was associated with shorter period of remission (DAS28≤2.6) during the first year of therapy. We have found no significant association between age, sex, socioeconomic status, years of education, depression symptoms, comorbidities and presence of rheumatoid factor or anticitrulinated antibodies and delay of the treatment.
Conclusions The patients living alone and with low disease activity at baseline are less likely to receive immediate DMARD's treatment. Delay of the treatment is associated with shorter time of remission during the first year of therapy. Awareness of factors associated with a delay in access to rheumatology care and DMARD therapy may help to reduce barriers that prevent early access and improve outcome in RA patients.
V.P.K. Nell, K.P. Machold, G. Eberl, T.A. Stamm, M. Uffmann, J.S. Smolen. Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology 2004;43:906–914
D.E. Feldman, S. Bernatsky, J. Haggerty, K. Leffondre, P. Tousignant, Y. Roy, Y. Xiao, M. Zummer, M. Abrahamowicz. Delay in Consultation With Specialists for Persons With Suspected New-Onset Rheumatoid Arthritis: A Population-Based Study. Arthritis & Rheumatism 2007;57:1419–1425
Disclosure of Interest None declared