Background/Purpose: A study of patients with RA at their first visit to an academic rheumatology site indicated an unexpected observation that 75% of patients had a history of prior treatment with either glucocorticoids or disease modifying antirheumatic drug (DMARD) agents, while only 25% were DMARD-naïve (1).  Therefore, we analyzed a hypothesis that DMARD-naïve RA patients would have greater improvement from first visit to 6-month follow-up visit than patients who had prior treatment, according to MDHAQ/RAPID3 (multidimensional health assessment questionnaire/routine assessment of patient index data3) scores.   

Methods: The first visit of all RA patients (by ICD codes) to one site that occurred between 5/2011-2/2017 was identified by retrospective chart review. All patients with all diagnoses complete MDHAQ/RAPID3 at all visits.  RAPID3 (0-30) is  the sum of 3 0-10 scores for physical function, pain visual analog scale (VAS), and patient global assessment VAS; severity categories are ≥12=high, 6.1-12= moderate, 3.1-6= mild, ≤3= remission. Patients who had a complete MDHAQ/RAPID3 at first visit and 6-month follow-up visit were  classified into 3 groups on the basis of prior DMARD therapy: 1)“DMARD-naïve” – no glucocorticoid or DMARD; 2) “active DMARD”- had DMARD therapy within previous month; 3)“DMARD-interrupted” – had prior DMARD therapy interrupted for > 1 month.   Mean MDHAQ/RAPID3 and individual RAPID3 component scores within each of the 3 groups were compared at first and 6-month follow-up visits for possible change using paired t tests.  Differences between the 3 groups in changes over 6 months were compared using analysis of variance (ANOVA).

Results: Demographic data for age, sex, ethnicity, level of formal education, as well as body mass index, did not differ significantly in the 3 RA groups.  Median disease duration was 1 year in DMARD-naïve patients, 2 years in active-DMARD, and 5 years in DMARD-interrupted patients (p=0.006).  Mean MDHAQ/RAPID3 scores were 15.5 in DMARD-naïve, 14.8 in active-DMARD, and 16.5 in DMARD-interrupted patients, all indicating high severity (≥12) – no clinically or statistically significant differences.  At 6-months follow up, MDHAQ/RAPID3 was improved in all RA groups, -5.7 in the DMARD-naïve group  vs -2.7 in the active DMARD group vs  -3.6 in the DMARD-interrupted group (p=0.05), also reflected in the RAPID3 component scores (Table).  The difference in the DMARD-naïve group, but not the other groups, exceeded the minimum clinically important improvement (MCII) criterion of 3.8 for MDHAQ/RAPID3, which was almost met in the DMARD-interrupted group, but not in the active-DMARD group. 

Conclusion: Patients with RA improved with treatment from first visit to 6 months later, greatest in DMARD-naïve, less in DMARD-interrupted, and least in the active-DMARD group.  The similarity of MDHAQ/RAPID3 scores at baseline of DMARD naïve to those of previously-treated patients suggests that “treat-to-target”  appears poorly implemented in routine clinical care.  The data appear to reinforce the importance of early treatment for optimal control of RA.

References: 1 -Chua et al, Arth Rheum, in press

table -3 RA groups-pdf2

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/dmard-naive-rheumatoid-arthritis-ra-patients-have-greater-rapid3-improvement-over-6-months-after-1st-visit-than-patients-who-were-treated-previously-treated-with-dmards-although-baseline-rapid3-was/