Background/Purpose Early initiation of disease-modifying anti-rheumatic drug (DMARD) therapy is recommended to improve rheumatoid arthritis (RA) outcomes. The aim of this study was to determine a) characteristics associated with early DMARD initiation (< 6 month of RA symptom) and b) impact of early DMARD therapy on outcomes at one year. 

Methods This is a retrospective study of newly diagnosed RA patients at a single academic center. Eligibility criteria were RA diagnosis made by a board-certified rheumatologist, follow-up of at least 12 months and no prior history of DMARD use (except corticosteroids). Data on socio-demographics; dates of symptom onset, visit to referring healthcare provider (PCP), receipt of referral, Rheumatologist appointment and DMARD therapy initiation; functional status by Multi-Dimensional Health Assessment Questionnaires (MDHAQ) & disease activity by Routine Assessment of Patient Index Data 3 (RAPID3); and initial and one year DMARD(s) therapy were extracted in standardized manner from medical records.  

Results 103 patients [71 (68.9%) females, 73 (70.9%) white; median (interquartile range, IQR) age of 50 (43-58) years, 74% anti-cyclic citrullinated peptide antibody positive] were found eligible. 50 (48.5%) were uninsured, 37 (35.9%) had Medicaid or Medicare and 16 (15.5%) had private insurance. Median (IQR) time from RA symptom onset to DMARD initiation was 51 (26-83) weeks. 25 (24.3%) patients had early DMARD therapy initiation. The delay from symptom onset to PCP visit contributed most to non-early DMARD therapy initiation followed by duration for receipt of PCP referral to Rheumatology appointment (Table). Uninsured patients were significantly less likely to receive early DMARD therapy, and were more likely to present with longer symptom duration to the PCP (p = .029), and have longer wait before getting Rheumatology appointment (p = .015).  No other socio-demographic factor was associated with early DMARD initiation. There were no differences in MDHAQ, RAPID3, or initial DMARD agent among the early and late DMARD therapy groups. However, early DMARD therapy group had better functional status and lesser requirement of traditional and biological DMARDs after 12 month.

Conclusion Only about one-fourth of RA patients received early DMARD therapy. Lack of insurance was associated with late DMARD therapy. Improved outcome and lesser need for intensive therapies were associated with early DMARD therapy. Our results supports need for improved insurance coverage as well improving awareness of early RA symptoms in general population and improving access to Rheumatology services.

Table: Comparison of patients who received early and late DMARD therapy.

Characteristics1	Early DMARD therapy (< 6 m)	Late DMARD therapy  (≥ 6 m)	P2
Sex, female	68	69.2	.908
Age, years	51 (39-65)	49 (44-55)	.360
Race, white	84	66.7	.097
Education, > 12y	38.1	28	.401
Marital status, married	65.2	59.3	.623
Insurance      Uninsured      Medicaid or Medicare      Private	32 60 8	53.8 28.2 17.9	.017
Patient’s home to Rheumatology clinic distance, miles*	67 (14.2-131)	50 (17-102)	.646
Symptom onset to PCP visit*, wks	4.5 (2.2-8)	44 (22-92.5)	<.001
PCP visit to referral placement*, wks	2 (0-4)	1 (0-3)	.130
Referral receipt to rheumatology appointment*, wks	5 (2-6)	7.5 (4-13)	.001
Rheumatology 1st appointment to DMARD therapy*, wks	0 (0-1.5)	0 (0-3.2)	.133
MDHAQ, 1st visit* (0-3)	1.3 (6.5-19.5)	1.3 (7.2-18.7)	.897
RAPID3, 1st visit* (0-30)	19.7 (14.8-23.3)	18.8 (14.3-23)	.898
RA treatment, 1st visit      Methotrexate      Hydroxychloroquine      Corticosteroid      Other DMARD	60 60 68 4	62.8 71.8 56.4 4.5	.800 .267 .305 .819
RA treatment,  12 month      Methotrexate      Hydroxychloroquine      Corticosteroid      Other DMARD      Biologics	84 80 60 12 0	72.4 90.8 56.6 31.6 14.5	.242 .148 .764 .069 .010
MDHAQ, 12 month* (0-3)	10.2 (5.0-13.1)	14.2 (7.5-19.8)	.027
RAPID3, 12 month* (0-30)	0.6 (0-0.8)	1 (0.3-1.3)	.090

¹All values in percentage (%), except variables with * represent median (IQR).

²P values from Chi-square, Fisher’s exact test or Mann-Whitney U test.

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