Objectives
To demonstrate that unsuccessful treatment optimisation in early disease is associated with difficult-to-treat rheumatoid arthritis (D2T-RA).
Methods
In this retrospective multicentre cohort study conducted from 09/2021–03/2022, we enrolled individuals fulfilling the 2010 ACR/EULAR RA criteria diagnosed 2000–2019. The outcome was D2T-RA by the EULAR definition. We used robust regression to examine the associations with delay, dose, duration of methotrexate, and discontinuation of glucocorticoids. We tested through multinomial regression which factors were associated with persistent inflammatory refractory RA (PIRRA) or non-inflammatory refractory RA (NIRRA). Sensitivity analysis included a case-control study matching the year of diagnosis.
Results
We enrolled 48 D2T-RA patients and 145 non-D2T-RA controls. Methotrexate was started within 3 months in 16.7% of D2T-RA vs 33.1% of non-D2T-RA (p= 0.011). Adequate duration of methotrexate was obtained in significantly fewer D2T-RA patients (70.8% vs 85.5%). Glucocorticoids were continued beyond 6 months in a higher proportion of D2T-RA patients (70.8% vs 33.8%, p< 0.001). In multiple regression, treatment delay beyond 3 months (OR 0.3; 95% CI 0.1; 0.9) and non-discontinuation of glucocorticoids after 6 months (OR 4.6; 95% CI 2.2; 9.5) were significantly associated with D2T-RA. Treatment delay was significantly associated with PIRRA only, whilst non-discontinuation of glucocorticoids was significantly associated with PIRRA and NIRRA. Results were replicated in sensitivity analyses.
Conclusion
Failure to start methotrexate within 3 months and not being off glucocorticoids within 6 months are early predictive features of D2T-RA.
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