PHILADELPHIA -- When rheumatoid arthritis symptoms persist despite disease-modifying therapies, few rheumatologists step up treatment as recommended by American College of Rheumatology (ACR) guidelines, a researcher said here.
Among patients who were clearly failing their current therapies, large majorities left rheumatology clinics with no change in treatment, reported Leslie Harrold, MD, MPH, of the University of Massachusetts Medical School in Worcester, Mass.
Moreover, she told attendees at the ACR's annual meeting, the situation has apparently not improved in the 16 months since the organization published guidelines calling for biologic treatments in most such patients.
"The results are terrible," Harrold said.
She and her colleagues analyzed data from the CORRONA registry, a prospectively maintained database of patients at about 60 rheumatology clinics across North America. She emphasized that the data therefore reflected practices by rheumatologists, not primary care physicians.
The data covered some 750 patients seen in CORRONA member clinics both before and after the ACR guidelines were issued in June 2008. They included records of patient status at clinic visits and the prescriptions they received.
About 60% of the patients were showing persistent disease activity while on methotrexate monotherapy. The others had failed at least two nonbiologic disease-modifying anti-rheumatic drugs (DMARDs).
The researchers also stratified patients according to whether disease activity was moderate or high according to Clinical Disease Activity Index scores. About half had moderate activity; mean scores across the entire sample were about 25.
Among 284 patients with persistent symptoms while on methotrexate monotherapy seen in the six months before the ACR treatment recommendations were published, just 9% with moderate disease activity and 8% of those with high activity were started on biologic drugs, Harrold reported.
Corresponding values for 200 patients seen in the six months following the guideline publication were 3% and 8%, she said.
"After the recommendations were published, nothing changed," Harrold said.
Regimens remained the same for the vast majority of patients, she said: 76% of those with moderate disease activity and 68% of those with high disease activity, before the guidelines were issued; and 86% and 62%, respectively, after they appeared.
Substantial numbers of patients -- about 10% of those with moderate activity and 25% of those with high activity -- actually were put on less intensive treatments, with all DMARDs stopped. The percentages were nearly identical in the pre- and postguideline periods.
The remainder had a nonbiologic DMARD added.
A very similar distribution of treatments was seen for patients who had failed multiple DMARDs, Harrold said. Use of biologics increased very slightly -- from 5% to 8% before June 2008 to 10% to 11% after -- but treatment in more than two-thirds of patients remained unchanged both before and after the ACR guidelines came out.
Even among patients seen a second time with persistent disease while on traditional DMARDs, biologics were initiated in less than 20%, Harrold reported.
"It does make one pause to see that there are so many people with active disease who have failed monotherapies that have not moved on to the next level," commented Joanne Jordan, MD, MPH, director of the University of North Carolina's arthritis research center in Chapel Hill, N.C., who was not involved in the study.
http://www.medpagetoday.com/Rheumatology/Arthritis/16524glad to be in the less than 20%just more evidence that we as medical consumers, patients with chronic disease, must be proactive in our on care. 2nd opinions, independent research, invlolvement in discusssions with out doctors are not luxeries they are essentials
I love my RD and I am grateful she is aggressive in her approach! Great article, Lynn, I hope everyone reads this.Those are some sad statistics. I wonder why rheumy's aren't following their own guidelines? The answer is self education and discussing in minute detail if needed our options and next steps. Fortunately, I've had an aggressive RD and will be starting a 3rd dmard along with the biologic and if that combo isn't working in 4 months time I'll move on to Orenicia. Lindy
[QUOTE=Katalina]Hi Lynn,Those are some sad statistics. I wonder why rheumy's aren't following their own guidelines? The answer is self education and discussing in minute detail if needed our options and next steps. Fortunately, I've had an aggressive RD and will be starting a 3rd dmard along with the biologic and if that combo isn't working in 4 months time I'll move on to Orenicia. Lindy
[/QUOTE] I think they may be a multitude of reasons including patient preference, side effects, cost risks etc. I would think this is a study that may need some digging into to actually understandYou're right Buckeye but on the surface they're a sad bunch of statistics. I would like to think that once they've done the first research that they'll fine tune it to include all the variables. It would be interesting. Lindymove up [QUOTE=buckeye]just more evidence that we as medical consumers, patients with chronic disease, must be proactive in our on care. 2nd opinions, independent research, invlolvement in discusssions with out doctors are not luxeries they are essentials
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