Background/Purpose: The window of opportunity concept states that there are superior clinical responses and the potential for remission, when patients with rheumatoid arthritis (RA) are managed earlier and aggressively with disease modifying anti-rheumatic drugs (DMARD). Benefits will be achieved if patients follow prescribed treatment reasonably close. Objectives of the study were to investigate whether timing of first non-persistence period and/or duration of persistence with DMARD during the first 4 years of follow-up predicted disease outcomes at the 5th year, in a cohort of early RA patients initiated in 2004 and to identify additional outcome´s predictors.

Methods: Up to February 2015, charts from 107 patients with at least 5 years of follow-up and prospective 6 month-apart assessments of disease activity, of disability and of persistence were reviewed. Non-persistence was defined as omission of at least one DMARD and/or corticosteroids for at least seven consecutive days; regarding methotrexate, one weekly missing dose was considered non-persistence. Persistence was recorded through an interview (up to 2008) and thereafter through a questionnaire; persistence duration was recorded in months. Treatment modifications because adverse events and/or indicated by a physician for any reason were not considered under non-persistent construct. At the 5^th year, disease activity was defined according to disease activity score on 28 joints (DAS28) and disability according to health assessment questionnaire (HAQ); both were derived as the mean of corresponding individual scores from all the visits performed during the 5th year. Descriptive statistics and linear and Cox regression analyses were used. All the patients signed informed consent.

Results:

At study entry, patients were more frequently middle-aged (39.1±13.3 years) female (88.8%), with high disease activity and disability; more than 80% had autoantibodies. Over the first 4 year´s follow-up, 54.2% of the patients were indicated oral corticosteroids and all traditional DMARDs. Almost 70% had at least 1 period of non-persistence and their follow-up (median, 25-75 quartiles [25Q-75Q]) to 1st non-persistence period was 13 months (1-31).

Gender, baseline DAS28 and persistence duration predicted DAS28 at the 5th year, and the strongest impact was due to months of persistence. Also, age and persistence duration predicted HAQ at the 5th year. When model were applied in female subpopulation, persistence duration still a predictor of subsequent outcomes. 

During the 5th year, 68 patients (56 women) achieved sustained remission (DAS28 below 2.6); in females (N=56, 83%), baseline DAS28 (OR: 0.65, 95% CI: 0.50-0.83, p=0.001) and persistence duration (OR: 1.04, 95% CI: 1-1.08, p=0.05) were its predictors. Also, 84 patients achieved sustained function (HAQ below 0.21) and baseline DAS28 and age were the only predictors. Timing of first non-persistence period did not impact outcomes.

Conclusion: Persistence duration with DMARDs within the first 4 years of the disease predicted subsequent favorable outcomes in early RA patients; additional predictors were younger age, male gender and lower disease activity at diagnosis.

« Back to 2015 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/window-of-opportunity-to-achieve-major-outcomes-in-early-rheumatoid-arthritis-patients-how-persistence-with-therapy-matters/