Background/Purpose : Early and aggressive therapy of Rheumatoid Arthritis (RA) with Disease Modifying Anti-Rheumatic Agents (DMARDs), glucocorticoids, and biologic agents is recommended by current treatment guidelines and supported by interventional studies with treat to target principles.(1) However, delays in initiation of therapy might be observed in real life. The objective of this analysis was to evaluate how frequently RA therapy is instituted promptly and to describe the characteristics of patients who are not treated early upon diagnosis.  

Methods:  The percentage of patients who at the time of enrollment in the Corrona Registry were not receiving any RA directed therapy was evaluated and their characteristics were summarized. The time to subsequent initiation of any RA directed therapy was also estimated.

Results : Out of the 35,485 patients enrolled in CORRONA, 20,317 (57.3%) had no prior use of prednisone, 18,299 (51.6%) had no prior biologic use, 16,930 (47.7%) had no prior DMARD use (excluding MTX), 15,335 (43.2%) had no prior MTX use. 2,166 (6.1%) had no prior nbDMARD use, and 750 (1.2%) had no history of receiving any RA directed therapy at the time of enrollment. For the patients without any history of RA directed therapy: age at the time of enrollment (mean ± SD) was 57.5±14.7 and age at RA onset was 52.3 ± 15.4 years. 69.4% were seropositive for RF and 60.6% for CCP antibodies. Patients had an overall established disease duration of 5.5 ± 9.0 years with only half (50.7%) having early disease (duration ≤1 year). CDAI was 18.3 ± 15.0; 34% of the patients had high and 27.6% moderate disease activity by CDAI. Subjects graded their fatigue as 35.6 ± 31.4 on a visual analog scale (0-100). Patients with no history of directed RA therapy did not have lower disease activity at enrollment compared with those receiving directed therapy. These patients were followed for a median (95% CI) time of 29.5 months (24.6-33.8). During the follow-up period, only 372 out of 750 (49.6%) patients initiated any RA directed therapy. The median time to initiation of any DMARD was 15.9 months (12.2-18.4) and to initiation of any RA directed therapy was 12.1 months (9.3-14.8). The Kaplan Meier survival estimates of RA therapies are shown in Figure 1.

Conclusion : In this registry analysis, a high percentage of patients with RA did not have a history of receiving directed therapy within a mean of approximately 5 years of RA onset. In those patients that had not received any RA directed therapy previously, approximately 50% did not initiate any therapy in 12 months of registry follow-up.

References:Jacobs, et. al.  J Clin Expert Rheum 2012;30:S39-43.

Figure 1. Kaplan Meier survival estimate to initiation of any RA Directed Drug (N=750)(Panel A), Non-Biologic DMARDs (including MTX) (Panel B),

Prednisone (Panel C) , and first Biologic ( Panel D)