In Undifferentiated Arthritis, DMARD-treatment Intensified During the Last Decennia but Did Not Result in Improved Outcomes

Marloes Verstappen, Xanthe Matthijssen and Annette H.M van der Helm-van Mil, Leiden University Medical Center, Leiden, Netherlands

Meeting: ACR Convergence 2021

Keywords: American College of Rheumatology Criteria, Clinical practice guidelines, Cohort Study, Disease-Modifying Antirheumatic Drugs (Dmards), rheumatoid arthritis

Session Information

Date: Saturday, November 6, 2021

Session Title: Miscellaneous Rheumatic & Inflammatory Diseases Poster I (0183–0209)

Session Type: Poster Session A

Session Time: 8:30AM-10:30AM

Background/Purpose: International guidelines stress timely DMARD-initiation in early arthritis, also when classification-criteria are not yet fulfilled. Consequently, undifferentiated arthritis (UA)-patients are increasingly treated despite placebo-controlled evidence for DMARD-effectivity in UA. Furthermore, since the introduction of the 2010 classification-criteria, the UA-population changed and trials including UA-patients not fulfilling the 1987- and 2010-criteria are absent. With 25-years of observational data, using inclusion-period as instrumental variable for DMARD-treatment, we studied whether enhanced treatment-strategies improved (long-term) outcome in UA.

Methods: UA was defined, in retrospect, as clinical arthritis neither fulfilling the 1987 nor the 2010 criteria for RA, nor any other distinct diagnosis. In total, 1132 UA-patients, consecutively included in the Leiden Early Arthritis Clinic between 1993-2019, were studied, divided into 5 inclusion-periods; 1993-1997, 1998-2005, 2006-2010, 2011-2014, 2015-2019. Frequency of DMARD-initiation was compared between the inclusion-periods as were the following outcomes: DAS28CRP and HAQ-DI during follow-up, prevalence of DMARD-free status (DFS; spontaneous remission or sustained remission after DMARD-stop) and progression to RA (according to the 1987 and/or 2010-criteria).

Results: The current UA-population has relatively mild disease; median SJC 1, TJC 2 and median HAQ 0.6. DMARD-treatment increased from 17% (1993-1997) up-to 52% (2015-2019), in which methotrexate became more common in the last decade. DAS28CRP during follow-up improved from 2011 onwards (range;-0.18,-0.25/p< 0.05). HAQ-scores remained similar (range;-0.00,-0.09/p >0.05), as did DFS-prevalence: 57%, 58%, 59% (1993-1997/1998-2005/2006-2010;p=0.59). Also, the percentage of patients that developed RA did not decrease (14%/21%/26%/18%/27% in the respective inclusion-periods).

Conclusion: Although intensified DMARD-treatment in UA might have led to lower disease activity scores, functionality and long-term outcomes did not improve, indicating potential overtreatment. Stratification methods for the up-to-date UA-population, to identify patients that will develop RA, are warranted.

Legend: Baseline disease activity scores and the decline in the first year did not differ between the inclusion periods. Disease activity after 1-year of follow-up improved from 2011 onwards. HAQ-DI scores at baseline and during follow-up remained similar in all inclusion periods, as did prevalence of DFS (spontaneous remission and sustained remission after DMARD-discontinuation). Also, percentage of patients who progressed to RA after 1-year did not improve.
DAS: disease activity score, CRP: C-reactive protein, HAQ-DI: Health Assessment Questionnaire Disability Index, DFS: DMARD-free status, RA: rheumatoid arthritis.

Legend: Baseline characteristics of the total UA-population and per inclusion period. Over time, UA-patients became older and symptom duration declined. Yet, disease activity and functional disability at baseline were comparable between the inclusion periods. Differences between inclusion periods were tested using ANOVA or Kruskal-Wallis test, as appropriate. Missing values were imputed and used for baseline table; values represent mean of the imputed medians calculated using Rubin’s rules.
ACPA: anticitrullinated protein antibody, CRP: C-reactive protein, DAS: disease activity score, ESR: estimated sedimentation rate, HAQ-DI: health assessment questionnaire disability index, SJC: swollen joint count, TJC: tender joint count, VAS: visual analogue scale.

Disclosures: M. Verstappen, None; X. Matthijssen, None; A. van der Helm-van Mil, None.

To cite this abstract in AMA style:

Verstappen M, Matthijssen X, van der Helm-van Mil A. In Undifferentiated Arthritis, DMARD-treatment Intensified During the Last Decennia but Did Not Result in Improved Outcomes [abstract]. Arthritis Rheumatol. 2021; 73 (suppl 9). https://acrabstracts.org/abstract/in-undifferentiated-arthritis-dmard-treatment-intensified-during-the-last-decennia-but-did-not-result-in-improved-outcomes/. Accessed June 1, 2023.

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