Tight control of RA might reduce subsequent disability

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.

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 disabilityThe 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 Â¥267 259 [approximately US $2236] per year in 2000 to Â¥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.)