Background/Purpose:

In order to overcome obstacles with overbooked outpatient clinics and lack of capacity to see rheumatoid patients frequently for treatment escalation, we established a protocol-driven clinic run by a speciality doctor and nurse in 2010. All newly diagnosed patients with Rheumatoid Arthritis were seen on a 4-6 weekly basis by the team to escalate DMARD treatment according to disease activity as measured by DAS28-CRP.  To assess DAS28-CRP remission rate in this cohort of patients (after 1, 2 and 3 years of therapy). We also looked at rates of low disease activity (LDA) – DAS 28 CRP≥2.6 but≤3.2 and categorisation by DMARD monotherapy, combination therapy, or Biologic therapy.

Methods:

Treatment escalation was done by agreed departmental protocol which included oral Methotrexate (up to 25mg/week, followed by S/C injections if necessary). This was followed by addition of Hydroxychloroquine and then either Leflunomide or sulphasalazine if DAS28-CRP indicated activity. UK NICE guidelines allow use of Biologics if the DAS > 5.1 at 6 months, hence this was the next step followed on the protocol.  We collected additional outcome data for HAQ score, work stability data, and radiological erosion data. We have 331 patients through the clinic to date and present outcome data for those completing 1year (127), 2years (75) and 3years (36).

Results:

127 patients have completed 1year, of which 20% achieved DAS28 scores <3.2 (LDA) and 60% <2.6 (remission). 64% needed combination DMARD therapy and 7 patients (5.5%) needed biologics, 30% remaining on DMARD monotherapy at 1 year. Mean HAQ scores reduced from 1.1 (+-0.01) to 0.32 (+-0.07) and radiological erosions progressed in only 10%. Job retention at one year was 90%.

75 patients completed 2 years of follow-up, 68% in DAS-remission and 16% LDA. 8% are on Biologics at end of year 2, 32% on DMARD monotherapy.

36 patients completed 3 years follow-up, with LDA in 25% and remission 61%. At year 3, Biologics use is 5.5%, with DMARD monotherapy in 20%.

DAS28 remission is maintained at 60% over the course of the 3years, with LDA increasing from 20% to 25% at year3. The active group (>3.2 DAS <5.1) who do not satisfy NICE criteria for Biologics reduced from 20% (year1) to 14% (year 3) on combination DMARD therapy.

Conclusion:

Targeted protocol-driven treatment of early RA with rapid escalation of therapy using conventional DMARDs/biologics resulted in remission of 60% at 1 year and maintained remission of 68% and 61% at 2 and 3 years.  The DAS28 remission rates and other outcomes achieved in this relatively ‘routine’ clinic are comparable to results achieved in controlled clinical trials. The innovative use of limited human resources and clinic appointments has provided good outcomes for patients with potential savings in expenditure on Biologic therapy.

Table: Comparison between Disease activity and therapy on consecutive 3 years

 

					YEAR 1 (2011)	YEAR 2 (2012)	YEAR 3 (2013)
Total number of patient= n					N=127	N=75	N=36
Disease activity	Active DAS-28 CRP > 3.2				26 (20%)	12 (16%)	5 (14%)
	Therapy	Monotherapy			6 (23%) one patient not on DMARD	4 (33%)	0 (0%)
		Combination			15 (58%)	5 (42%)	4 (80%)
		Biologics			4 (15%)	3 (25%)	1 (20%)
	Low DAS-28 CRP ≥2.6 but ≤ 3.2				25 (20%)	12 (16%)	9 (25%)
	Therapy			Monotherapy	9 (36%)	4 (33%)	1 (11%)
				Combination	15 (60%)	7 (59%)	8 (89%)
				Biologics	1 (4%)	1 (8%)	0 (0%)
	Remission DAS-28 CRP is < 2.6				76 (60%)	51 (68%)	22 (61%)
	Therapy		Monotherapy		23 (30%)	16 (31%)	6 (27%)
			Combination		51 (67%)	33 (65%)	15 (68%)
			Biologics		2 (3%)	2 (4%)	1 (5%)

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