San Diego—October 28, 2013
Delaying treatment for rheumatoid arthritis could greatly increase the likelihood that patients will suffer joint damage and experience disability two years out, according to a new study from Vivian Bykerk, M.D. at Hospital for Special Surgery. The research was presented at the annual meeting of the American College of Rheumatology/Association of Rheumatology Health Professionals on October 28 in San Diego.
“We need to educate people diagnosed with rheumatoid arthritis about this. Some want to delay treatment because they are afraid. They haven’t wrapped their heads around the fact that they have this disease, or they are reluctant to start taking medication. Some resort to non-medicinal approaches, many of which have limited effect,” said Dr. Bykerk, lead investigator and a rheumatologist at Hospital for Special Surgery in New York City.
“Unfortunately, I have seen too many people delay effective treatment approaches and they come back a year later very disappointed, often with joint damage that could have been prevented. The longer you have inflammation in the joints, the more likely you are to have joint damage, and it is going to impact how you function down the road,” she said.
Rheumatoid arthritis (RA) is a systemic autoimmune disease that mainly affects the joints. The current standard of initial therapy is early use of antirheumatic drugs, which have been proven effective at reducing RA-related inflammation. So far, alternative medicines and weaker therapies have not proven to be effective for the disease in well-designed placebo-controlled clinical trials.
The new study identified patients with early RA, and classified them six months later as having reached “low disease activity,” or not. Low disease activity, the goal early in the course of the disease, means that joint pain, swelling and other markers of inflammation are markedly reduced. When comparing patients at two years, investigators observed that those whose RA had reached a state of low disease activity by six months had much better functional ability at two years. In a related study from this group, function was found to be even better at two years in patients who had reached full remission.
The study was conducted using data from the Canadian early ArThritis Cohort (CATCH). Dr. Bykerk is chair and director of CATCH, an ongoing multicenter research project in Canada that has been collecting information on patients with early inflammatory arthritis. Patient data have been collected at 19 clinical sites across Canada, in both teaching and community-based hospitals, as well as clinics. So far, the project has collected data on 1,800 patients.
Dr. Bykerk and Dr. Pooneh Akhavan, along with their research group, used the database to identify 833 patients with early RA who had been followed for two years. Early RA was defined as having symptoms for one year or less. Investigators assessed the impact of low disease activity (LDA) at six months on the level of disability at two years, using the health assessment questionnaire (HAQ) disability index. The HAQ is a self-reported survey that has become a dominant instrument used in assessing RA. It gauges the difficulty that a patient has in performing basic activities, including walking, bathing, eating and dressing.
In analyzing the impact of achieving early low disease activity, the researchers adjusted for potential confounding factors such as baseline function and disease activity, as well as age, sex, and use of disease-modifying antirheumatic drugs (DMARDS), steroids, and biologics. More than 90% of patients received DMARDs. The researchers also controlled for levels of rheumatoid factor (the autoantibody most relevant to rheumatoid arthritis) and erythrocyte sedimentation rate (a measure of inflammation). An exploratory analysis examined whether socioeconomic status, pain, and fibromyalgia had an impact on disability.
The researchers found that achieving LDA at six months was a significant, independent predictor of lower disability at two years; 56% of patients achieved a LDA at six months. “It turns out that at two years into the study, patients who got their disease under control sooner had better function than the ones who did not,” said Dr. Bykerk. As suspected, patient age and sex were also predictive of disability (women generally have worse RA than men), and patients with fibromyalgia at baseline also had more disability.
“We believe there is a window in which people have a much better chance of getting rheumatoid arthritis under good control, often with less intense therapy, and the window is within the first three months of developing joint inflammation,” said Dr. Bykerk. The new study results, she said, should prompt doctors to warn patients about the hazards of delaying therapy and follow patients more often in the initial phases of treatment.
“I believe that patients should meet with their arthritis specialists often in the early phases of RA so that they can assess how their patients are responding to treatment,” Dr. Bykerk said. “The longer patients wait, the more likely it is that they will need more intense therapy to achieve the same control of joint inflammation.”
Previously, studies have shown that better disease control in the first year predicted less future disability. This study shortens the gap.
About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.