Abstract:Objective
We examined the treatment patterns among adults with rheumatoid arthritis (RA) and identified factors influencing access to traditional and biological disease modifying antirheumatic drugs (DMARDs).
Methods
We analyzed visits recorded in the National Ambulatory Medical Care Survey from 2005 to 2014 with a RA diagnosis. The primary outcome was DMARD use (traditional and/or biological). We included prescriptions of all RA-related treatments such as traditional and biological DMARDs, glucocorticoids, … Show more
“…The unit of analysis is the ambulatory visit associated with an RA diagnosis and not persons with RA, and RA cases are not followed longitudinally over 12 years because different individuals are sampled every year. Similar to other studies using NAMCS data with acceptable accuracy, we used up to the first three diagnoses and eight medications to evaluate DMARD use for visits likely to have been for RA ( 13 , 14 ). However, diagnosis cannot be confirmed, and medication data are not validated against the prescription date, nor do they include dosage information.…”
Section: Discussionmentioning
confidence: 99%
“…In an early study using NAMCS data from 1996 to 2007, Solomon et al showed most visits coded with RA did not have an associated DMARD prescription ( 13 ). Another study using later NAMCS data showed any DMARD use was associated with visits with specialists and Medicare beneficiaries (2005‐2014) ( 14 ). However, these studies did not focus on older adults and did not evaluate variations in DMARD prescriptions by provider specialty over time.…”
Objective
We compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).
Methods
In this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.
Results
We identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).
Conclusion
DMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.
“…The unit of analysis is the ambulatory visit associated with an RA diagnosis and not persons with RA, and RA cases are not followed longitudinally over 12 years because different individuals are sampled every year. Similar to other studies using NAMCS data with acceptable accuracy, we used up to the first three diagnoses and eight medications to evaluate DMARD use for visits likely to have been for RA ( 13 , 14 ). However, diagnosis cannot be confirmed, and medication data are not validated against the prescription date, nor do they include dosage information.…”
Section: Discussionmentioning
confidence: 99%
“…In an early study using NAMCS data from 1996 to 2007, Solomon et al showed most visits coded with RA did not have an associated DMARD prescription ( 13 ). Another study using later NAMCS data showed any DMARD use was associated with visits with specialists and Medicare beneficiaries (2005‐2014) ( 14 ). However, these studies did not focus on older adults and did not evaluate variations in DMARD prescriptions by provider specialty over time.…”
Objective
We compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).
Methods
In this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.
Results
We identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).
Conclusion
DMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.
“…Such factors as data collection interval, race, provider type (general physician vs. specialist), and type of drug coverage are associated with the use of DMARDs or biological agents among RA patients [10], and financial burden of certain expensive biological agents, usually leads to insufficient treatment among RA patients [10]. The data collection interval in this study was between 1998 and 2012, and during which period, the most available biologics agents for RA were etanercept (etanercept was available in Taiwan was since May 12, 2005) and adalimumab (adalimumab was available in Taiwan was since Aug 19, 2008).…”
Section: Discussionmentioning
confidence: 99%
“…The use of biological agents has been associated with significantly increased rates of serious infections, including opportunistic infections and bacterial infections, in most studies [9], and the outcomes of adverse drug effects has resulted in most guidelines recommending biological agents to be used in patients who had responded poorly to or who were intolerant of one or more DMARDs [10]. According to one recent study [11], autoantibodies and markers of systemic or local inflammation can be present long before clinical arthritis, and the disease process evolves long before the disease is clinically detectable, i.e., early treatment in RA patients should be associated with improved outcomes [11].…”
Comparison between early biologics treatment and late biologics treatment of rheumatoid arthritis (RA) patients in decreasing prescription days of glucocorticoids and painkillers by using the Taiwan National Health Insurance Research database from January 1, 1997 to December 31, 2013. We defined early use of biologics as biologics prescribed within 2.24 years after the RA diagnosis, and the late use of biologics was defined as those prescribed after 2.24 years of the RA diagnosis. These definitions are based on previous studies defining early arthritis as arthritis within 2 years of diagnosis, while we needed another 3 months for application biologics here in Taiwan, which equals a total of 2.24 years. Among the 821 patients, 410 patients (50%) were classified in the Early group, and the other 411 patients (50%) were classified in the Late group. The use of any of these three types of medication, including steroids, disease modifying antirhuematic drugs, and nonsteroid anti-inflammatory drug (NSAID) was changed significantly after biologics treatment. Comparing between before and after biologics treatment, oral medication was significantly tapered (all p <0.0001). The results show that men are 1.81 times more likely than women to taper oral glucocorticoids and NSAIDs. Younger age (<45) patients are 1.91 times more likely to taper steroids and NSAIDs than those aged over 65 years old. Both gender and age were found to be independent factors that could decrease days of prescription of both steroids and NSAIDs in early use of biologics agents. This study indicates that younger patients only need short-term (2.53±1.92 years, p=0.03) and early treatment with biologics (within 2.24 years of diagnosis of RA), just in order to taper steroids and NSAIDs to less than 50% than before biologics treatment.Comparison of glucocorticoids and painkiller prescribed days between rheumatoid arthritis patients receiving early and late treatment with a biological agent via a population-based cohort study.
“…These symptoms are often indicators of moderate stage RA or the sequential stages.The administration of long-term treatment medications is generally delivered to patients in moderate stage RA and beyond. These include a class of drugs called disease-modifying anti-rheumatic medications (DMARDs) such as methotrexate, hydroxychloroquine, and sulfasalazine, which aid in the suppression of inflammation [36].…”
Rheumatoid Arthritis (RA) is an autoimmune disease that targets the synovial joints of the body that holds a massive burden on healthcare worldwide. The progression of the disease is mediated in congruence of the adaptive immune cells (T-and B-cells) and synovial fibroblast activation. In the last decade, standard treatment options for RA have demonstrated significant improvements but often fail to deliver a long-term therapeutic outcome and, in some cases, cause adverse effects leading to treatment termination. Treatment with mesenchymal stem cells (MSCs) has been recently studied in RA because of the unique immunomodulatory and anti-inflammatory capacities of the MSCs needed to combat RA. Pre-clinical and clinical trials have demonstrated that MSCs derived from adipose tissue, bone marrow, and umbilical cord tissue possess immunomodulatory capabilities that alter the dysfunctional immune cells involved with the pathogenesis of autoimmune diseases including RA. Specifically, these trials have demonstrated the immunomodulation ability of MSCs on the proliferation of memory T cells as well as their ability to migrate to inflamed tissue associated with synovitis in RA.
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