Barriers to Optimal Disease Control for Rheumatoid Arthritis Patients With Moderate and High Disease Activity

Abstract

Objective. To evaluate barriers that prevent rheumatoid arthritis (RA) patients from achieving Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) scores within the current recommended levels for low disease activity (LDA) or clinical remission (DAS28-ESR score <3.2). Methods. Using an electronic medical record program, clinical data for RA patients treated in Optimising Patient Outcomes in Australian Rheumatology clinics, with a recorded DAS28-ESR score, were collected at one point in time. The data included demographics, medications, disease measures, and the rheumatologist's opinion of the main barriers preventing improvement to the recommended DAS28 score. Results. Of the 4,037 patients with a recorded DAS28-ESR score, 304 patients (7.5%) had high disease activity (HDA) and 1,211 patients (30%) had moderate disease activity (MDA). For 584 HDA or MDA patients, the barriers to disease control (BTCs) were recorded by the rheumatologist when there was no adjustment to disease-modifying antirheumatic drug (DMARD) therapy. The recorded BTCs were irreversible joint damage (19.7%), patient-driven preference (14.7%), noninflammatory musculoskeletal pain (9.2%), insufficient time to assess the effect of recently initiated DMARDs (9.2%), safety concerns (7.5%), comorbidities (6.5%), resistant disease (6.3%), and other less common reasons. These patients received DMARDs (97.4%), including biologic agents (34.1%), methotrexate (74.8%), and oral corticosteroids (41.8%). Conclusion. This study identified clinical situations in which rheumatologists elected to continue RA patients with MDA or HDA on DMARD therapy without adjustment to achieve clinical remission or an LDA target of a DAS28-ESR score <3.2.

Are We Able to Suppress Disease Activity Adequately in Patients With Established Rheumatoid Arthritis? An Observational and Cross-Sectional Study

“…We determined that overall remission and LDA were achieved in half of the study sample. In two reports from a developed country, 8,9 the proportions of patients with MDA and HDA were lower than ours, but still quite high by 39% (number of study population=5,686) and 37.5% (number of study population=4,037), respectively. In a report on a multicenter study from Turkey that used the Turkish League Against Rheumatism RA registry data, 4 the overall proportion of patients with MDA and HDA was reported to be 68% (number of study population=2,539).…”

“…Comorbidities, older age, irreversible joint damage, patientdriven preference, safety concerns, and resistant disease might hamper management of the disease. 9,10 Although not the focus of our study, some barriers including increased disease duration and inadequate medication were also identified. DMARDs may lose efficacy over time or patients may develop intolerance to them.…”

“…13 The dimension of 'patient global assessment of disease activity' of the composite indices used in RA may be influenced by non-inflammatory pain syndromes such as fibromyalgia and depression, particularly in patients with long-standing disease. 9,10 The management of RA depends primarily on the use of DMARDs, 2 MTX being the anchor drug.…”

Successes, challenges and developments in Australian rheumatology

“…One example of excel lence in connecting care is that of the OPAL (Optimising Patient outcomes in Australian RheumatoLogy) consortium, a collaborative network of Australian privatepractice rheumatologists who agree to share a clinical record system for data gathering; this group has now published several studies in their large combined cohort, demonstrating that c ollaborative action is possible. [67][68][69] In Figure 1b, we present a model for a more connected Australian healthcare system. We suggest that access to health care data across providers would greatly improve efficiency and outcomes in chronic disease management; in addition, a move from the currently predominant model of independent clinician practice settings to one in which groups of GPs, rheumatologists, orthopaedic surgeons and allied health practitioners operate as musculoskeletal centres could further boost efficiency and reduce patients' sense of disconnection from their carers.…”

The Past versus the Present, 1980-2004: Reduction of Mean Initial Low-Dose, Long-Term Glucocorticoid Therapy in Rheumatoid Arthritis from 10.3 to 3.6 mg/Day, Concomitant with Early Methotrexate, with Long-Term Effectiveness and Safety of Less than 5 mg/Day

“…The RA clinical trials which showed greatest efficacy involve a ‘treat-to-target' strategy, generally without biological agents - such as FinRACo [87], TICORA [88], BeSt [89], NEO-RACo [100], CAMERA [90] and CIMESTRA [91] - rather than a classical design to compare a biological agent in a fixed dose to a control therapy (which, however, is required to register a new agent). The limited responses in most trials may be explained as much by the presence of joint damage and/or fibromyalgia as by the absence of anti-inflammatory activity [92]. …”