Background/Purpose: Disease modifying anti-rheumatic drugs (DMARDs) are standard initial treatments for rheumatoid arthritis (RA).  Many RA treatment guidelines have been published including from the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) and British Society for Rheumatology (BSR).  However, there is little evidence to demonstrate that guidelines alter prescribing practice.  BSR guidelines for treatment of RA were published in 2006 and recommended initiation of DMARDs in the first 90 days after RA diagnosis. We aimed to test whether publication of these guidelines changed clinical practice.

Methods: We used the Clinical Practice Research Datalink, consisting of primary care records & prescriptions, secondary care referral details, procedures and diagnoses, for >10 million patients from a representative sample of primary care practices in the UK. DMARDs are usually initiated in the UK by a rheumatologist, with ongoing DMARD prescribing usually performed by primary care physicians with supervision by a rheumatologist. Incident diagnoses of RA in persons aged ≥18 years between 1995-2010 were identified. For each calendar year and quarter, the proportion of patients receiving any DMARD prescription within 90 days and 1 year of diagnosis was ascertained. An interrupted time-series regression model was used to assess whether trends in the proportion of patients receiving DMARDs within 90 days and 1 year changed following publication of the 2006 BSR Guidelines.

Results: Between 1995 and 2010, 25,963 incident cases of RA were identified, 69% female, average age of diagnosis 59 years. There was a progressive increase in the proportion of patients prescribed a DMARD by a primary care physician within 90 days from 16.6% in 1995 to 23.5% in 2005. The proportion receiving DMARD/s within 90 days increased more rapidly following publication of the BSR guidelines (Figure 1) to 27.9% by end 2006 and 36.0% in 2010 (p=0.01). A similar pattern was observed for the proportion of patients receiving DMARD/s within 365 days of diagnosis (p=0.002).

Conclusion: The proportion of patients prescribed a DMARD in primary care in this study is lower than generally accepted estimates. This may reflect reality for patients with RA outside of specialist centres although secondary care prescribing is not captured within this database. Nevertheless, prescriptions that are captured should be representative of overall trends in prescriptions within the UK and suggests that guidelines published by a national body can improve the proportion of patients receiving DMARD treatment in the first year after diagnosis of RA.