Earlier Visits More Likely to Result in Sustained DMARD-Free Remission for Patients With RA

June 9, 2020

Recommendations that patients with rheumatoid arthritis see an expert within 6 weeks of symptom onset can provide challenges for practices.

Following recommendations to visit a rheumatologist within 6 weeks of symptom onset for patients with arthritis has benefits, but may not be necessary depending on the goal, according to results published in The Lancet Rheumatology.1

Lead author Ellis Niemantsverdriet, PhD, of the Department of Rheumatology at the Leiden University Medical Center in Leiden, Netherlands, explained during a presentation2 of the findings at the European Congress of Rheumatology of the European League Against Rheumatism (EULAR), that implementing the recommendation to be seen within 6 weeks “provides huge logistical challenges.”

“In addition, currently, there is no evidence that the first visit within 6 weeks leads to improved long-term outcomes compared with a first visit between 7 and 12 weeks,” she said. “And therefore, we investigated if time to encounter a rheumatologist within 6 weeks compared with 7 to 12 weeks results in better disease long-term outcomes.”

The study included 1539 patients with rheumatoid arthritis from the Leiden Early Arthritis Clinic (n = 1025; between January 1, 1996, and December 31, 2017) and the French Etude et Suivi des Polyarthrites Indifferenciées Recentes (n = 514; between November 1, 2002, and April 30, 2005). The patients were grouped based on the time from symptom onset and first visit with a rheumatologist: within 6 weeks (EULAR recommendation), between 7 and 12 weeks, and after 12 weeks.

After 7 years, 24% (30 of 127) of patients in the Leiden Early Arthritis Clinic who visited a rheumatologist within 6 weeks, 20% (45 of 223) with a visit between 7 and 12 weeks, and 15% (100 of 675) with a visit after 12 weeks achieved sustained disease-modifying antirheumatic drug (DMARD)-free remission. After 10 years of follow-up in the French Etude et Suivi des Polyarthrites Indifferenciées Recentes, 27% (3 of 11) of patients with a visit of 6 weeks or less after symptom onset, 11% (11 of 100) with a visit between 7 and 12 weeks, and 10% (41 of 403) with a visit after 12 weeks had sustained DMARD-free remission.

A multivariable analysis found that patients had similar radiographic progression regardless of if they saw a rheumatologist within 6 weeks, between 7 and 12 weeks, or after 12 weeks.

The authors concluded that deciding whether or not to implement the recommendation to see a rheumatologist within 6 weeks of symptom onset “might depend on the long-term treatment aim.” Since sticking to that timeline did have a beneficial effect on “sustained DMARD-free remission,” but the timeline is not necessary to minimize structural damage.

“Since clinically relevant joint destruction has become infrequent and sustained DMARD-free remission is increasingly achievable, achieving a time to encounter within 6 weeks, although challenging, might become of increasing importance,” the authors concluded.

References

1. Niemantsverdriet E, Dougados M, Combe B, van der Helm-van Mil, AHM. Referring early arthritis patients within 6 weeks versus 12 weeks after symptom onset: an observational cohort study. Lancet Rheumatol. 2020;2(6):e332-338. doi:10.1016/S2665-9913(20)30061-8

2. Niemantsverdriet E, Dougados M, Combe B, van der Helm-van Mil, AHM. Is referring early arthritis patients within 6 weeks associated with better long-term outcomes than referring within 12 weeks after symptom onset? — investigating the evidence for the first EULAR recommendation for early arthritis in two observational cohorts. Presented at: EULAR 2020; June 3-6, 2020; Abstract OP0222.