Background/Purpose: Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) are recommended as the first-line treatment for patients with rheumatoid arthritis (RA). Guidelines recommend escalation of treatment to combinations of csDMARD and/or biologics for those with moderate to high disease activity despite treatment with csDMARDs. We sought to characterize disease burden among RA patients who had been on a csDMARD for at least six months and who had not transitioned to a biologic.

Methods: We identified patients enrolled in the US Corrona RA Registry between 06/01/2014 and 1/30/2018 who had been receiving a csDMARD continuously for at least 6 months, remained biologic naïve, were in moderate or high disease activity (Clinical Disease Activity Index [CDAI] >10) and had at least one follow-up visit.  Disease activity was assessed in the subset of patients with a 6 month follow-up visit (+/- 3 months) comparing those who achieved remission/low disease activity (CDAI≤10) to those who remained in moderate/high disease activity (CDAI>10) in terms of demographics, lifestyle factors, comorbid conditions and disease characteristics using descriptive statistics. 

Results:  There were 525 patients who met study inclusion criteria, with a mean age of 65 (SD 13), mean duration of RA of 11 years (SD 11), and mean duration of csDMARD therapy of 397 days (SD 210).  In those with a 6 month visit (n=409), more than half (n=219) remained in moderate/high disease activity (54%) at follow up.  Those who achieved remission/low disease activity (n=190) were similar to those in moderate/high disease activity (n=219) at their 6 month visit with respect to age, BMI, comorbid conditions (history of serious infection, cardiovascular disease, malignancy), duration of RA and prednisone dosage.  Baseline swollen and tender joint counts were higher in those who did not achieve remission/low disease activity; a higher proportion of those reaching remission/low disease activity were college educated or higher (39%) compared with 27% (Table). Over the 6-month period, treatment acceleration occurred in <30% of patients.  Dose escalation of the csDMARD, initiation of another csDMARD and initiation of a biologic DMARD occurred in 57 (14%), 33 (8%) and 42 (10%) of the total population of patients respectively.

Conclusion:   Substantial numbers of patients on csDMARDs have persistent moderate/high disease activity over 6 months of follow-up. These observations indicate that there is considerable need for a treat to target approach to care to prevent joint damage and physical disability and maximize long-term health-related quality of life.