Background/Purpose: Treatment of rheumatoid arthritis is directed to “treat-to-target,” with intensification of therapy in patients with moderate/high disease activity according to a quantitative index toward low disease activity or remission. However, remission or even low disease activity is unusual in even 50% of patients. One study suggests a partial explanation, as about 20% of patients with high index scores whose therapy is not intensified had clinically important joint damage (1). We analyzed physician estimates of inflammation and damage in RA patients in two ways: a) quantitative physician 0-10 visual analog scales (VAS); and b) estimates of the proportion(s) of clinical management decisions attributable to inflammation, damage, and/or distress, totaling 100%.

Methods: All patients seen at a one academic site completed an MDHAQ/RAPID3, and rheumatologists completed a RheuMetric physician checklist which includes 4 0-10 VAS for overall global estimate, inflammation, damage, and distress. A second type of scale asks doctors to estimate the proportion of the decision concerning management that is attributable to inflammation, damage, or distress, totaling 100%. Only the inflammation and damage VAS and proportions are analyzed in this study. Cross tabulations were computed with categories 0-1.9, 2-3.9,4-5.9,6-7.9,and 8-10 for the 0-10 VAS, and 0-19%, 20-39%, 40-59% 60-79%, and 80-100% for the proportion of the decision attributable to inflammation or damage.

Results: Among 72 patients studied, a 0-10 inflammation VAS was estimated as 8-10 in 6% of patients, versus 6-7.9 in 4%, 4-5.9 in 14%, 2-3.9 in 38%, and 0-1.9 in 39% of patients. Overall, only 24% of patients had scores ≥4 for inflammation. Damage was estimated at 8-10 in 10% of patients, 6-7.9 in 10%, 4-5.9 in 18%, 2-3.9 in 40%, and 0-1.9 in 22%; 37% of patients had damage scores ≥4 . The proportion of clinical management attributable to inflammation was estimated as 80-100% in 10% of patients, 60-79% in 15%, 40-59% in 24%, 20-39% in 18%, and 0-19% in 33%. Damage was estimated as impacting 80-100% of the clinical decision in 36%, 60-79% in 8%, 40-59% in 24%, 20-39% in 18%, and 0-19% in 14% of patients. Overall, inflammation accounted for more than 40% of clinical decisions in 49% of patients, while damage accounted for more than 40% of decisions in 68% of patients.

Conclusion: In one setting, damage appears to impact clinical decisions in contemporary treatment of patients with RA as much as inflammation. This finding may explain in part why clinical trials of established patients indicate only 60% ACR20 responses with all 10 approved biological agents for RA, and may also explain in part why fewer patients than might be expected are in remission. The data suggest that quantitative assessment of physician VASs to assess inflammation and damage (and distress) may be informative in routine care.

Reference: 1)Tymms K, et al. Arthritis Care Res (Hoboken). 2014;66(2):190-6.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/limitations-of-treat-to-target-in-rheumatoid-arthritis-joint-damage-appears-as-severe-as-inflammation-in-contemporary-care-at-one-site/