Background/Purpose

We have previously shown that in early rheumatoid arthritis (RA) remission targeted, intensive combination treatment, regardless of initial infliximab, results in remission in most patients. Still, patients’ adherence to medication in RA is often poor and difficult to improve. Little attention, however, has been focused on the effect of physicians’ adherence.

Methods

In the Neo-RACo study 99 patients with early, active RA were treated with methotrexate, sulfasalazine, hydroxychloroquine and low-dose prednisolone for 2 years. Patients were randomized to receive either infliximab or placebo for 6 months from week 4. All swollen joints had to be injected with intra-articular glucocorticoids. After 2 years, medication could be tapered down in the case of remission. In non-remission, treatments were unrestricted, including the use of biologics. At all times, treatment aimed at strict Neo-RACo remission defined as no swollen or tender joints and presence of 5 out of the 6 following criteria: morning stiffness <15 minutes; no fatigue; no joint pain; no tender joints; no swelling in joints or tendons; and ESR <30 mm/h in women and <20 mm/h in men. During a 5-year follow-up, strict remission rates, disease activity score 28 (DAS28) levels, radiological changes, anti-rheumatic medication after 2 years, and cumulative days off work were assessed. Physicians’ (n=30) adherence during 15 study visits between 0 and 24 months was evaluated with a scoring system. On every visit, lack of glucocorticoid injections (0.2–0.4 points), lack of medication adjustments (0.4 points), and poor filling of the study forms (0.2 points) were assessed. Also, 0.5–1.0 points were given if a study visit was cancelled. The patients were divided into tertiles by the sum of the points for inactivity between 0 and 24 months. Factors contributing to remission rates at 3 and 24 months were evaluated. 

Results

Follow-up data were available on 93 patients. Mean of the sum of the points for inactivity was higher in the placebo group (2.67±2.25) than in the infliximab group (2.09±1.71, p=0.032). Physicians’ adherence (p<0.001), duration of symptoms (p=0.037) and the use of infliximab (p=0.016) predicted strict remissions in a multivariable model at 3 months, whereas at 24 months physicians’ adherence (p<0.001) was the sole independent predictor. We found a relationship favoring active treatment on strict Neo-RACo remission rates, which were 77.4%, 62.7% and 46.7% (p=0.018) in the actively treated, the intermediately treated, and the inactively treated at 2 years. The respective figures at 3 years were 80.0%, 56.3% and 53.3% (p=0.048), at 4 years 73.3%, 75.0% and 41.4% (p=0.025), and at 5 years 63.6%, 65.6% and 51.7% (p=0.40). In addition, the DAS28 levels were lower in the actively treated than in the intermediately and the inactively treated at all time points. There were no significant differences in radiological progression and cumulative days off work between tertiles of treatment activity. After the first 24 months, biologics were used more often among the inactively treated compared with the intermediately and the actively treated (p=0.024).

Conclusion

Physicians’ active stance is crucial for the targeted treatment of RA to work.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/impact-of-physicians-adherence-to-treat-to-target-strategy-on-outcomes-in-early-rheumatoid-arthritis/