Rome, Italy—In a study presented at the 2015 annual meeting of the European League Against Rheumatology, the 5-year risk for major joint surgery was similar for patients with moderate rheumatoid arthritis (RA) compared with those with persistently high levels of disease activity. Results suggest that patients with RA who cannot achieve low disease activity with conventional disease-modifying antirheumatic drugs (DMARDs) should be treated more intensively with a biologic. This would require revisiting the guidelines for treatment of RA in the United States and the United Kingdom.
Although it is common knowledge that persistently high disease activity leads to worse outcomes in patients with RA, it is not well known that moderate disease activity poses a similar risk for joint destruction, explained lead author Elena Nikiphorou, MD, of St. Albans City Hospital in Hertfordshire, UK.
“Our data provide an argument for updating existing disease activity cut-off points for all patients with moderate disease activity so they can receive a biologic agent in addition to conventional disease-modifying antirheumatic drugs,” she stated.
The data she reported were based on 2071 patients with early RA who participated in the Early RA Study and the Early RA Network. At least 2 disease activity scores (DASs) were available from year 1 to year 5 for 2044 of the 2071 participants. All patients received conventional DMARDs, and some were given biologics in more recent years.
The need for orthopedic surgery over the first 5 years was used as a surrogate marker for joint destruction and treatment failure. Over the follow-up period, 1602 orthopedic surgeries were documented in the study cohort. Large joint replacement was categorized as major surgery; synovectomy, joint fusion, and arthroplasty of the wrist, hand, and foot were categorized as intermediate surgery; and soft-tissue surgery was considered minor surgery.
Mean DAS was calculated for each patient from year 1 to year 5. A DAS of <2.6 was considered remission; 2.6 to 3.19 was considered low disease activity; 3.2 to 4.19 was low-moderate disease activity; 4.2 to 5.1 was high-moderate disease activity; and >5.1 was high disease activity.
After controlling for confounding variables, the risk of major joint surgery over the study period was higher in patients with low-moderate, high-moderate, and high disease activity compared with low disease activity (P <.005 for all categories vs low disease activity). Patients in all 3 disease activity categories were at least twice as likely to require major surgery over the 5-year period. The risk was 2.5 times higher in patients with high disease activity than in those with low disease activity (P <.001).
According to Nikiphorou, this study suggests that patients with moderate RA disease activity despite treatment with conventional DMARDs have a similar risk for major surgery as those with high disease activity. “The goal of keeping patients in the low disease activity state is important for long-term outcomes,” she stated. “People with moderate disease activity are clearly progressing, even if it is subclinical.”
The study was conducted in England, where patients with moderate disease activity are not treated with biologics. Nikiphorou said that she hopes this study and others like it will be considered when making national recommendations and guidelines.
In the United States, the 2012 American College of Rheumatology guidelines for treatment of RA recommend anti–tumor necrosis factor therapy in combination with DMARDs for patients with high disease activity and features of poor prognosis.
Nikiphorou E, Carpenter L, Norton S, et al. Different levels of moderate disease in rheumatoid arthritis (RA) are associated with varying risk for joint destruction and failure: time to update DAS cut-offs for biologic DMARD use? Presented at: 16th Annual European Congress of Rheumatology; June 10-13, 2015; Rome, Italy. Abstract OP0179.