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Early rheumatoid arthritis (RA) treatment leads to improvement in long-term outcomes, according to a study published in Arthritis & Rheumatology.1
The objectives of the inception cohort study were to report outcomes for patients with RA and to determine how early treatment affected mortality and disability over a period of 20 years following the onset of symptoms.
A research team at the Arthritis Research UK Centre for Epidemiology at the University of Manchester in the United Kingdom selected patients who had enrolled between 1990 and 1994 in the Norfolk Arthritis Register (NOAR), a community-based registry of patients presenting with inflammatory polyarthritis. Those patients who met the criteria for a diagnosis of RA according to the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) were enrolled in the study, which included 602 patients (median age at symptom onset: 56; 65.9% women): 193 who were not prescribed treatment for RA (“no treatment”), 249 (72.3% women) who were prescribed treatment 6 months or more after symptom onset (“late treatment”), and 260 (53.1% women) who received treatment within 6 months of treatment onset (“early treatment”). The early treatment group received sulfasalazine (58.8%), steroids (28.1%), methotrexate (5.0%), or another disease-modifying antirheumatic drug (DMARD, 8.1%). Treatment was initiated between 6 to 12 months following the appearance of symptoms for 19.9% of patients in the late treatment group, between 1 and 2 years for 17.4% of those patients, and after 2 years for 19.0% of those patients; 43.7% of patients were never treated.
Study participants were evaluated using 51 swollen joint counts (SJC51), 51 tender joint counts (TJC51), and the British version of the Health Assessment Questionnaire – Disability Index (HAQ) and were assessed for current use of DMARD at baseline and at 1, 2, 3, 5, 7, 10, 15, and 20 years after enrollment.
Data analysis showed that at 20 years, HAQ scores, which provide a measure of functional disability, were improved in the early treatment group compared with the late treatment group (n=207, β 0.03; 95% CI, -0.06 to 0.12). HAQ scores for those who received early treatment were found equivalent to those for patients who never required treatment. A trend toward reduced risk of mortality was observed in the early treatment group. Median swollen and tender joint counts fell after baseline and stayed low over the follow-up period across treatment groups (SJC 1-3, TJC 3-6). Long-term outcomes in the study cohort were superior to those seen in a long-term study of patients with RA recruited between 1964 and 1966, most of whom received then-standard treatments of steroids, gold, and chloroquine.2 In the current study, the median HAQ score across treatment groups at 20 years was 1.38, indicating low to moderate disability. The older study saw a 19% rate of patients with severe disability after 20 years.
Summary and Clinical Applicability
“Considering the treatment provided 20 years ago, patients experienced relatively good long-term outcomes, including functional disability,” commented co-investigator Suzanne Verstappen, PhD, in an interview with Rheumatology Advisor. “After adjusting for the fact that patients with more severe disease activity would be prescribed certain therapies more often, there was no difference in functional disability between patients who received therapy within the first 6 months and those who did not receive any treatment. We also found that patients who were treated in the first 6 months had a lower risk of death, although this result was not significantly different. These results indicate that early treatment is not only of significance in the short term, but also in the long term.”
Study Limitations
- Standard treatment received by participants in the study does not reflect contemporary treatment practices.
- SJC and TJC were not assessed at 5 and 7 years following enrollment in the study and thus could not be included in the longitudinal analysis.
- The proportion of patients in the late treatment group who received no treatment was high (32.1%).
References
- Gwinnutt JM, Symmons DP, MacGregor AJ, et al. The 20 year outcome and association between early treatment and mortality and disability in an inception cohort of patients with rheumatoid arthritis: Results from the Norfolk Arthritis Register [published online April 20, 2017]. Arthritis Rheumatol. doi:10.1002/art.40090
- Scott DL, Symmons DP, Coulton BL, Popert AJ. Long-term outcome of treating rheumatoid arthritis: results after 20 years. Lancet. 1987;1(8542):1108-1111.
