RESEARCH - Tight control of RA disease activity can prevent disability progression, but moderate control does not

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Tight control of RA might reduce subsequent disability

Abstract

Tight control of rheumatoid-arthritis (RA) disease activity is emerging as a

key strategy for preventing the progression of RA-related disability said

data presented at the 2005 ACR/ARHP Annual Scientific Meeting.

Complete Article

3 Dec 2005

Dr Hisashi Yamanaka (Tokyo Women's Medical University, Japan) reported that

tight control of disease activity (to Disease Activity Score 28 [DAS28]

<3.2) can prevent disability progression, but moderate control does not [1].

Dr Eiichi Tanaka (Tokyo Women's Medical University) suggested that tight

control and improved RA disease activity levels are likely to translate into

reduced long-term medical costs [2].

Dr Theodore Pincus (Vanderbilt University, Nashville, TN) reported that

tighter control of inflammation by earlier use of methotrexate (MTX)

resulted in better clinical status over 10 years [3].

Taken together, these studies suggest that " tight control " is likely to

become standard practice in RA because it prevents disability, saves money,

and improves clinical status.

Early MTX, aggressive disease control prevent disability

The Yamanaka and Tanaka presentations used data from a prospective

observational cohort of more than 6000 RA patients. Clinical data were

collected biannually and included the patient's self report, physician

assessment, and laboratory data. Yamanaka's analysis included 1940 patients,

with an average disease duration of 10.3 years.

" Several recent clinical researchers have emphasized the necessity of the

tight control of disease activity for the prevention of structural damage in

patients with RA. Most of these studies were investigated in randomized

controlled trials [RCTs]; however, the results of RCTs are sometimes

unsuitable to apply directly in daily practice. To investigate the necessity

of the tight control of disease activity in daily practice, we investigated

the relationship between the disease activity and the progression of

disability in a large observational cohort of RA patients, " Yamanaka said.

Patients were divided into three groups based on the average DAS28 over the

previous four years. These were poorly controlled (average DAS28 >5.1),

moderately controlled (average DAS28 2.3-5.1) and well controlled (average

DAS28 <3.2). Progression of disability was assessed using the Japanese

version of the Health Assessment Questionnaire (J-HAQ).

" Over the past 4.5 years we observed a dramatic improvement in DAS28 scores

and changes in the medications used, " Yamanaka said. " This included a

dramatic increase in use of methotrexate and a decrease in use of

prednisone. We think that the widespread use of higher doses of methotrexate

resulted in these improvements. "

HAQ score and DAS28 score were closely related at baseline. In the poorly

controlled group, the HAQ increased from 1.43 to 1.68 over the trial period.

HAQ scores also increased from 0.88 to 1.00 in the patients with moderately

controlled disease activity.

" On the other hand, in the well-controlled group, the HAQ score was 0.40 at

entry and 0.37 at four years, indicating that disability was not getting

worse and was getting better in some patients, those whose average DAS28 was

<2.6, whose HAQ improved from 0.294 to 0.249. Tight control of disease

activity prevented the progression of disability in daily practice, "

Yamanaka concluded.

Tanaka noted that this has not yet translated into a net saving in costs of

care, but he expects the significant improvements in DAS28 (p<0.0001) to

lead to reductions in medical costs over the long term.

" The average outpatient cost gradually increased (+8% in 4.5 years) from

g??267 259 [approximately US $2236] per year in 2000 to g??289 375

[approximately US $2420] per year in 2004. Medications accounted for about

50% of total outpatient cost, which increased 31% during the 4.5 years

observed. Infusion costs increased with the introduction of infliximab

(+223% per 4.5 years), " Tanaka said.

It is interesting to note that the improvements in patients studied by

Tanaka and Yamanaka occurred without the use of biologics. Tanaka said that

only about 3% of RA patients in Japan receive biologics.

Similarly, Pincus reported that earlier use of methotrexate in the standard

care of RA patients is becoming more common and is associated with better

clinical status.

This analysis used two databases of RA patients seen in Jyvaskyla, Finland

and Nashville, TN. The database was analyzed in five-year periods for time

from presentation to initiation of methotrexate, number of years of

follow-up, and proportion of patients treated with methotrexate in each

period. Time to beginning methotrexate declined from 14 years during 1980-84

to 0.5 years in 2000-2004 in the Finnish patients and similarly in the

American ones, but early methotrexate use was adopted five to 10 years

earlier in Nashville than in Jyvaskyla. Clinical status over time improved

in both populations.

" Improved [erythrocyte sedimentation rate] ESR, HAQ, and [Multidimensional

Health Assessment Questionnaire] MHAQ scores were seen over these periods,

associated with aggressive therapy both in a higher proportion of patients

and earlier onset of MTX use, although a secular trend toward milder disease

may also be present. These data suggest that the strategy to use MTX early

in disease may be as important as the drug itself in the management of RA, "

Pincus concluded.

(Source: (1) Yamanaka H, Inoue E, Tanaka E, et al. Tight controls of the

disease activity successfully prevent the progression of disability in a

large observational cohort of rheumatoid arthritis patients in Japan. 2005

ACR/ARHP Annual Scientific Meeting; November 12-17, 2005; San Diego, CA.

Abstract 1181.

(2) Tanaka E, Kamitsuji S, Inoue E, et al. Tight control of the disease

activity may lead to reduced medical costs for care of patients with

rheumatoid arthritis?? " analysis of medical cost for care using a large

cohort database. 2005 ACR/ARHP Annual Scientific Meeting; November 12-17,

2005; San Diego, CA. Abstract 553

(3) Pincus T, Sokka T. Toward " tight control " of inflammation in patients

with rheumatoid arthritis: Earlier use of methotrexate in standard care of

patients with RA in 2 settings in the US and Finland over 25 years,

1980-2004, associated with improved clinical status. 2005 ACR/ARHP Annual

Scientific Meeting; November 12-17, 2005; San Diego, CA. Abstract 894.

Rheumawire: Joint & Bone: December 2005.)

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