Early Diagnosis and Treatment in Patients with RA

Orlando—With the incidence of patients with rheumatoid arthritis (RA) increasing and the disease currently the leading cause of chronic disability per capita in the United States, healthcare professionals are seeking ways to achieve better outcomes. According to studies and RA experts, treating patients as soon as possible after they are diagnosed with RA leads to improved response to treatment as well as reduced comorbidities. Wesley Mizutani, MD, medical director of clinical research at Talbert Medical Group in California, stressed the importance of early diagnosis and early treatment of RA at the NAMCP meeting in a session titled Optimizing Treatment Strategies in Rheumatoid Arthritis. In the United States, 2.2 million adults have RA, and 20% to 30% become disabled during the first 3 years of the disease, according to Dr. Mizutani. Of RA cases, 75% occur in women; 1% to 3% of women will develop RA during their lifetime. The standardized mortality ratio (the ratio of observed deaths to expected deaths) is 1.27 in all RA patients and 1.40 in women who have RA. Dr. Mizutani said numerous comorbidities are associated with RA, including chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, dementia, and lymphoma. Dr. Mizutani cited several studies examining the effect of early treatment in RA patients. A trial published in the American Journal of Medicine compared people treated within 2 weeks of diagnosis with those treated 3 months after diagnosis. At 24 months, the patients who waited longer had 5 times as many erosions compared with the patients who received early treatment. Another study in Arthritis & Rheumatism showed that 74% of patients treated within 2 years of RA diagnosis with methotrexate (MTX) and a tumor necrosis factor (TNF) inhibitor achieved low-level disease activity after 1 year. Patients taking MTX and a TNF inhibitor also had significantly less radiographic progression compared with patients receiving MTX alone or MTX plus disease-modifying antirheumatic drugs (DMARDs). In addition, a meta-analysis that appeared in Rheumatology indicated that patients treated with MTX had a 70% reduction in cardiovascular disease (CVD) rates compared with those who never received MTX. Patients taking MTX leading to a clinical response decreased CVD morbidity by 15% to 35% compared with patients not taking MTX. To evaluate RA patients and measure how they respond to treatment, Dr. Mizutani recommended using metrics such as the Disease Activity Score using 28 joint counts, the Clinical Disease Activity Index, and the Routine Assessment of Patient Index Data scores. There are numerous therapies available for RA patients. Nonbiologic DMARDs include MTX, plaquenil, sulfasalazine, and leflunomide; biologic DMARDs include etanercept, infliximab, adalimumab, certolizumab pegol, golimumab, anakinra, abatacept, tocilizumab, and rituximab. Dr. Mizutani said 60% of patients taking biologic DMARDs improve by 20%, 40% of patients taking biologic DMARDs improve by 50%, and 20% of patients taking biologic DMARDs improve by 70%. The number of severe adverse events is similar in patients taking biologic or nonbiologic DMARDs, according to Dr. Mizutani. However, biologic DMARDs are associated with an increased risk for infections and tuberculosis (TB). Dr. Mizutani said patients with significant infections requiring antibiotic treatment should discontinue taking biologic DMARDs, while patients considered for biologic DMARDs should undergo screening for latent TB.