RA Treatment Still Lagging Behind ACR Recommendations

Janis C. Kelly

March 08, 2012

March 8, 2011 — Evidence-based treatment recommendations typically require 17 years to affect routine patient care, and recent analysis of experience with the American College of Rheumatology (ACR) recommendations for rheumatoid arthritis (RA) suggests that RA care continues to follow that slow trajectory.

Leslie R. Harrold, MD, MPH, from the University of Massachusetts Medical School in Worcester, and colleagues report in an article published in the March issue of Arthritis & Rheumatism that RA treatment in the United States did not change at all after publication of the guidelines, and that more than half of patients with RA who have moderately or highly active disease still do not receive care consistent with the guidelines, mostly because they are undertreated.

Coauthor Daniel E. Furst, MD, Carl M. Pearson Professor in Rheumatology at the University of California, Los Angeles, told Medscape Medical News, "Publication of the guidelines did not significantly affect treatment patterns within the period of follow-up. It is possible that it will take longer than was followed to percolate through to changes in practice. A case in point is the fact that studies of [methotrexate] MTX for RA definitively showed that MTX was effective by mid-late 1980s, but the drug did not become the mainstay of therapy for about 5 to 7 years thereafter — and even later in Europe.

 "Also, at least in some cases, the treatments in some patients may have been different from the recommendation, but we are not yet willing to say that that means the care was inappropriate. As has been noted repeatedly, the recommendations are generalized for the average patient, and numerous exceptions can, and perhaps should, be made, given individual patient needs. Having said that, it is still disappointing that the uptake was at this level at this point in time. It says we must do a better job in disseminating and convincing rheumatologists."

The analysis was done using data from a US cohort of 1632 biologics-naive patients with RA from the Consortium of Rheumatology Researchers of North America (CORRONA) registry. All patients were under care of a rheumatologist and had visits before and/or at least 6 months after publication of the ACR recommendations. The comparison periods were from February 2002 to June 2008 vs from December 2008 to December 2009. The ACR recommendations were published in June 2008.

The study participants were divided into MTX users (n = 791) and multiple nonbiologic disease-modifying antirheumatic drug (DMARD) users (n = 841) and were under the care of 204 rheumatologists, 95 of whom cared for patients in both the prepublication and postpublication cohorts. From medical records, the researchers assessed "[i]nitiation or dose escalation of biologic and nonbiologic DMARDs in response to active disease...in comparison to the ACR recommendations."

In the MTX monotherapy group, the researchers found care consistent with ACR treatment recommendations for from 90% to 93% of patients with low disease activity, from 83% to 91% of patients with moderate disease activity and good prognosis, but only for from 24% to 29% of patients with moderate disease activity and poor prognosis and 34% to 37% of patients with high disease activity.

Similarly, in the multiple nonbiologic DMARD group, care consistent with treatment recommendations was given to from 89% to 94% of patients with low disease activity and to 43% to 51% of patients with moderate disease activity with a poor prognosis or severe disease activity.

"We found that adherence to the treatment recommendations was lower for patients with higher levels of disease activity, specifically because a majority of these higher-risk patients continued to receive less aggressive therapies rather than undergoing accelerated treatment," the authors write.

They suggest that a contributing factor might be lack of awareness of the patient's disease activity at the time of the visit.

"While it is possible for providers to calculate the [Clinical Disease Activity Index], Routine Assessment of Patient Index Data Score, or global arthritis score at the time of the clinical encounter, in many instances these are calculated only after the fact, if at all. It is known that many rheumatologists rely, instead, on a variably determined qualitative physician global assessment to inform their treatment decisions," the researchers write. They also note that rheumatologists might have been unaware of the ACR recommendations at the time of the study, "although these recommendations were published in a journal associated with the ACR, are available currently on the ACR web site, and were highlighted in a plenary session at the annual meeting occurring immediately after their publication."

Another possibility is that RA care might be subject to the "clinical inertia" seen in other cases of failure to reliably accelerate treatments for patients with uncontrolled disease, and "lack of response to evidence-based treatment recommendations is typical of the care of all chronic diseases in the US," the authors write. They suggest that this problem is worsened by the lack of infrastructure in the United States for capturing disease activity status at each visit and transmitting that information to both physician and patient in a timely manner.

"Redesigning clinical care so that patients and providers have real-time information on disease activity as well as summaries of the risks and benefits of DMARD therapy based on disease activity is crucial and necessary to enable personalized treatment that is tailored to the specific needs of the patient and to improve long-term disease outcomes," they conclude.

Rheumatologist and Arthur Kavanaugh, MD, reviewed the study for Medscape Medical News. Dr. Kavanaugh, who is professor of medicine at the University of California, San Diego, Division of Rheumatology, Allergy and Immunology, said, "There are always multiple factors involved. The CORRONA database is a good one, in that it includes actual doctors and their actual patients. Still, one never knows all the reasons why treatments may not be started. For example, patients tend to be conservative [and] are less likely to take risks to get better than they are to prevent getting worse."

The CORRONA registry is supported by Abbott, Amgen, Bristol-Myers Squibb, Centocor, Genentech, Lilly, and Roche. Dr. Harrold’s work was supported by the National Institutes of Health, as was that of 2 coauthors, the work of one of whom was also supported by the Arthritis Foundation. Other authors disclosed consulting fees from Innovations Consulting, CME Outfitters, Health Interactions, Elsevier, Pfizer, Bristol-Myers Squibb, Cresdendro, Abbott, Actelion, Biogen Idec, Gilead, GlaxoSmithKline, Merck, Nitec, Novartis, UCB, Wyeth, and Zoma. Dr. Kavanaugh has disclosed no relevant financial relationships.

Arthritis Rheum. 2012;64:630-638. Abstract

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