A study of more than 50,000 US patients suggests that rheumatologists may not be practising what they preach.
Treat-to-target has been an important principle in rheumatology for over a decade – but a study of more than 50,000 US patients suggests that rheumatologists may not be practising what they preach.
An analysis of data from a national registry in the US showed that between one-third and two-thirds of RA patients with poorly-controlled disease did not switch medications within a year, despite drug adjustment being recommended by EULAR and ACR guidelines.
“These findings shine a spotlight on the relatively high proportion of patients who fail to change RA therapies despite not achieving the treat-to-target goals of low disease activity or remission,” Jeffrey Curtis, a professor of medicine at The University of Alabama at Birmingham and the study’s co-author, said.
The study was presented at the ACR/APHP Annual Meeting in Chicago in October. In order to conduct the real-world study, the researchers extracted data on 50,996 adult RA patients from the ACR’s Rheumatology Informatics System for Effectiveness (RISE).
RISE is intended to be a minimal-effort registry that automatically gathers clinical practice data relating to almost half a million US patients without any added input from clinicians.
The average age of RA patients included in the study was 62, and the majority were women.
Many RA patients were not eligible for the study because their doctors were not measuring disease activity.
“In many cases, their doctor was not documenting anything,” Professor Curtis said. “It was the, ‘Hi, how are you feeling? Does anything hurt?’ type of approach. A lot of rheumatologists think that is good enough but … you cannot improve something you aren’t measuring.”
Out of all the RA patients who had a RAPID3 and/or CDAI disease measure taken at least twice in one year, the researchers selected only the patients with moderate or high disease activity.
In this cohort of patients with poorly controlled RA, 37% to 58% did not change treatments after 7 to 12 months.
“There were a couple of important factors that give us clues as to the reasons why people weren’t changing treatments,” Professor Curtis said. “Firstly, what background therapy you were on was hugely important.”
About two-thirds of RA patients that were not on a biologic or targeted therapy added one of those drugs to their treatment within one year if their disease activity continued to be moderate or high.
“For patients already on, say, methotrexate and a biologic, only about a third of people changed their treatment over the next year,” he said.
People over the age of 75 were less likely to change therapies, and some doctors were more willing to suggest new treatments than others.
The research confirmed patients with moderate to severe disease activity who switched therapies had a demonstrable improvement in symptoms over the study period. Professor Curtis said the apparent “clinical inertia” was concerning as it reflected a care gap where guidelines were not being followed.
“Frankly, as a field we need to better practise what we preach,” he said.
