Seeing Expert Earlier Increases Chance of Sustained DMARD-Free Remission

May 01, 2020
Ellis Niemantsverdriet, PhD

Ellis Niemantsverdriet, PhD

Seeing a rheumatologist within 6 weeks of symptom onset was beneficial for patients with rheumatoid arthritis to achieve sustained disease-modifying antirheumatic drug (DMARD)-free remission, recent study findings showed.

The findings emphasized that it might become increasingly important to achieve a time to encounter a patient within 6 weeks to make DMARD-free remission attainable.

Ellis Niemantsverdriet, PhD, and a team of Europe-based investigators analyzed patients with rheumatoid arthritis to learn whether visiting a rheumatologist within 6 weeks of symptom onset was related to better long-term outcomes compared with seeing a professional 7-12 weeks after symptom onset.

Niemantsverdriet, from the rheumatology department at Leiden University Medical Center in the Netherlands, and the team included patients with rheumatoid arthritis from the Leiden Early Arthritis Clinic (EAC) and the French Etude et Suivi des Polyarthrites Indifferenciées Recentes (ESPOIR) cohorts.

The EAC included patients >18 years old with clinically confirmed inflammatory arthritis at their initial physical exam. The patients’ symptoms lasted <2 years. Patients were followed up at 3, 6, and 12 months, then yearly.

In the ESPOIR cohort, patients were recruited from 14 French rheumatology centers. Patients were 18-70 years old with a rheumatoid arthritis diagnosis or were suspected to develop the condition based on expertise from a rheumatologist. The patients from the cohort had >2 swollen joints at their initial exam.

Each patient in the ESPOIR cohort was followed up every 6 months for 2 years then yearly until a maximum of 10 years.

All patients included in the team’s study were DMARD-naïve at the time of their first rheumatology visit.

The primary outcomes were sustained DMARD-free remission and radiographic progression. Niemantsverdriet and colleagues defined sustained DMARD-free remission as the sustained absence of arthritis after stopping DMARD therapy for the entire period of follow up.

The investigators used radiographs of hands and feet to study radiographic progression. The images were scored according to the Sharp-van der Heijde scoring method.

Overall, 3585 patients with early arthritis were included in the EAC cohort, 36% of which were diagnosed with rheumatoid arthritis. Some patients were excluded due to missing data, leaving the final sample included in the analysis at 1025.

A total of 514 patients with rheumatoid arthritis were included in the ESPOIR cohort.

In the EAC group, the median follow-up was 7.1 years (IQR, 3.9-12.2), while it was 10 years (IQR, 9-10) in the ESPOIR group.

Following 7 years of follow-up in the EAC, 24% of patients with an encounter of <6 weeks, 20% of patients with a time of 7-12 weeks, and 100% of patients with a time of >12 weeks achieved sustained DMARD-free remission. In a multivariable analysis, those in the EAC group who saw a rheumatologist within 6 weeks had sustained DMARD-free remission more often than those seen between 7-12 weeks (HR, 1.59; 95% CI, 1.02-2.49; P=.042) and after 12 weeks (HR, 1.54; 95% CI, 1.04-2.29; P=.032).

Among those in the ESPOIR cohort, after analysis, there were similar but non-significant effects observed (HR, 2.81; 95% CI, .75-10.53; P=.12 within 6 weeks vs 7-12 weeks) and (HR, 3.05; 95% CI, .89-10.49; P=.077 within 6 weeks vs more than 12 weeks).

In both cohorts, there was a higher chance of achieving sustained DMARD-free remission if the time to encounter was <6 weeks compared to 7-12 weeks (HR, 1.69; 95% CI, 1.1-2.57; P=.016) and >12 weeks (HR, 1.67; 95% CI, 1.08-2.58; P=.02).

For radiographic progression, those who saw a rheumatologist within 6 weeks had similar progression to those seen between 7-12 weeks in both cohorts (95% CI, .95–1.05; P=.96, in the EAC; and (95% CI, .8–1.07; P=.3, in ESPOIR). There were similar findings for those seen after 12 weeks (95% CI, .92–1, P=.064) in the EAC and (95% CI, .77–1.02; P=.1) in ESPOIR.

The team found that although less time to encounter was associated with an increased chance of sustained DMARD-free remission, there was not a reduction in severity of radiographic progression.

The findings added knowledge about whether to implement the EULAR recommendation of time to encounter a rheumatologist within 6 weeks. The investigators suggested it could depend on the long-term treatment aim.

The study, “Referring early arthritis patients within 6 weeks versus 12 weeks after symptom onset: an observational cohort study,” was published online in The Lancet Rheumatology.
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