Treatment Change Uncommon Despite Elevated Disease Activity in RA

Clasped hands of an elderly lady resting on a table alongside a variety of scattered medication tablets capsule and pills prescribed for her health and as diet.
One- to two-thirds of patients failed to modify rheumatoid arthritis treatment, even when they were in moderate or high disease activity.

Between one- and two-thirds of patients do not change their rheumatoid arthritis (RA) treatment despite experiencing moderate or high disease activity, according to research published in Arthritis Care & Research.

Using data from the American College of Rheumatology Rheumatology Informatics System for Effectiveness (RISE) Registry, a national electronic health record-based registry, researchers identified the measurement tools rheumatologists use to evaluate patient disease activity, describe medication use, treatment changes, and treatment response in RA over time. Researchers assessed how discordant disease activity measurement via different tools affects RA treatment changes.

The 2016-2017 RISE data included 457,950 patients, of whom 34% had at least 1 clinic visit with a valid disease activity measure. Of these, 50,996 adults were included in the cohort (mean age 62.4±13.7 years; 76.7% women; 68.8% white), with 27,274 adults with RA eligible for longitudinal analysis. More than 50% of the patients had Medicare coverage.

Overall, data from the 16 weeks before the index visit showed that 25.4% of patients were receiving conventional synthetic disease-modifying antirheumatic drug (csDMARD) monotherapy, 16.2% were receiving biologic monotherapy, 5.1% were receiving csDMARD combination therapy, and 12.2% were receiving both a biologic and a csDMARD. Additionally, 24.9% of patients were also using nonsteroidal anti-inflammatory drugs, 15.9% were using narcotics, 25.3% were using oral glucocorticoids, and 8.4% were using antidepressants.

Based on disease activity measurements at the index visit, 85.0% of the cohort were evaluated using only 1 type of RA disease activity measurement; 14.2% were evaluated using 2 measurement instruments, most commonly RAPID3 and the Clinical Disease Activity Index (CDAI); and 0.8% were evaluated using at least 3 measurement instruments. Among those who were evaluated via RAPID3, 28.9% were in disease remission, 19.3% had low disease activity, 23.0% had moderate disease activity, and 28.9% had high disease activity.

Researchers also evaluated treatment strategies in patients with moderate or high disease activity. Among those measured via RAPID3 who were using csDMARD monotherapy, 54.6% added or switched to either csDMARDs or biologic DMARDs (bDMARDs) during follow-up. Of the patients taking bDMARD monotherapy, 53.2% added or switched to csDMARDs or bDMARDs. Of the patients taking combination csDMARDs or combination bDMARDs, 45.9% and 35.6%, respectively, added or switched to csDMARDs or bDMARDs. Patients measured via CDAI followed a similar pattern of treatment change.

When the cohort was restricted to patients with moderate or high disease activity measured by either RAPID3 or CDAI, who had both measures available, 61.7% of patients taking csDMARD monotherapy, 56.6% taking bDMARD monotherapy, 34.5% taking combination csDMARD therapy, and 45.1% of patient taking combination bDMARDs therapy at the index visit underwent a treatment change during follow-up.

Patients with high disease activity measured by RAPID3 experienced a median change in RAPID3 units of -2.4 between the index and main outcome visits (mean change -4.1). Patients who started with moderate disease activity experienced a median change of -0.9 units (mean change -0.7). Of those measured with the CDAI, median changes were -13.0 and -3.0 for high and moderate disease activity (mean change -13.3 and -2.6, respectively).

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Several factors influenced treatment change including recent initiation of treatment with an RA drug, high disease activity at the index visit, no current DMARD use, commercial insurance coverage, obesity, NSAID or glucocorticoid use, prior use of tumor necrosis factor inhibitors or non-tumor necrosis factor inhibitors, and csDMARD treatment.

Study limitations included the use of only 18 months of RISE data and possible misclassification of medication use based on prescriptions and the fact that the data may not be generalizable to the wider population.

“We found that one- to two-thirds of patients failed to modify RA treatment, even when they were experiencing moderate [or] high disease activity,” the researchers concluded. “Multimodal treat-to-target interventions directed both at patients and providers are needed to encourage shared decision-making and goal-directed care, as well as to overcome barriers to RA treatment change.”

Disclosure: This clinical trial was supported by Eli Lilly and Company. Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Yun H, Chen L, Xie F, et al. Do patients with moderate or high disease activity escalate rheumatoid arthritis therapy according to treat-to-target principles? Results from the Rheumatology Informatics System for Effectiveness registry of the American College of Rheumatology. 2020;72(2):166-175.