Positive outcomes in rheumatoid arthritis (RA) are closely linked to early diagnosis and treatment with disease-modifying antirheumatic drugs (DMARDs). A study by researchers in the Netherlands found that patients who are assessed by rheumatologists soon after RA symptoms appear are more likely to experience less joint destruction and improved chances of DMARD-free disease remission. Details of this novel study are published in the December issue of Arthritis & Rheumatism, a journal of the American College of Rheumatology.
The World Health Organization (WHO) estimates that RA affects up to 1% of the population worldwide and is associated with increased morbidity, mortality, and healthcare costs. This chronic, systemic disease is characterized by inflammation in the lining of the joints which can frequently lead to joint damage. Current medical evidence suggests that early initiation of an optimal RA treatment strategy—within 12 weeks of symptom onset—can prevent joint damage, improve long-term function, and increase the likelihood of achieving disease remission.
Dr. Michael van der Linden and colleagues from the Leiden University Medical Center examined 1674 early arthritis patients from the Leiden Early Arthritis Clinic cohort. Of those participants, 598 (36%) were RA patients who were diagnosed between 1993 and 2006. Researchers studied the associations among total delay to physician assessment, achievement of DMARD-free-remission, and the rate of joint damage over a six-year follow-up period. Total delay was calculated as the sum of "patient delay" (time from symptom onset until patient seeks and is assessed by a general practitioner (GP)) and "GP delay" (time lapse between seeing the GP and a referral to- and appointment with a rheumatologist).
Results showed the median patient, GP, and total delay in evaluation of early arthritis patients were 2.4, 8.0, and 13.7 weeks, respectively. "Early treatment intervention dramatically improves clinical outcomes in patients with RA," said Dr. van der Linden. "Our study presents the first evidence that RA patients who have a delay longer than 12 weeks between first symptoms and visiting a rheumatologist have a higher rate of joint destruction and lower chance of achieving a sustained DMARD-free remission." In 69% of RA patients, an examination by a rheumatologist took place 12 or more weeks after symptoms began, which researchers suggest contributed to a joint destruction rate that was 1.3 times higher than patients assessed prior to 12 weeks. A delay in treatment was also associated with greater risk (1.87 hazard ratio) of not achieving DMARD-free disease remission.
In a related editorial published in this month's issue, Dr. Paul Emery, Arthritis Research UK Professor of Rheumatology and Head of Musculoskeletal Diseases at Chapel Allerton Hospital in the United Kingdom and Dr. Vivian Bykerk from Brigham and Women's Hospital in Boston, Massachusetts point out that previous studies showed delays to care are frequent, but the study by van der Linden et al. was the first to actually document the negative impact of delayed RA treatment. "These data provide further evidence that rheumatologists have the greatest impact on patients with RA when they intervene early in the disease course," commented Dr. Emery. He further noted strategies that may help reduce delays in care such as prescreening referrals, an introduction of a specialized rheumatology referral form for GPs to use that identify urgent referrals, or set-up of central triage clinics.
Dr. van der Linden concluded, "Our results highlight the importance of reducing the delay in assessment by a rheumatologist and further studies could test whether accelerated treatment leads to improved disease outcomes in RA." The ACR and European League Against Rheumatism (EULAR) have set up a task force to address the issue of improving RA patient outcomes through early intervention.