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Walsh JA, Pei S, Alexander S, Braaten T, Walker JH, Clewell J, Douglas KM, Penmetsa GK, Ye X, Breviu B, Cannon GW, Kunkel GA, Sauer BC. Missed opportunities for treatment of inflammatory arthritis and factors associated with non-treatment: An observational cohort study in United States Veterans with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis. Semin Arthritis Rheum 2024; 66:152436. [PMID: 38714073 DOI: 10.1016/j.semarthrit.2024.152436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE To identify factors associated with non-treatment with biologic and non-biologic disease modifying anti-rheumatic drugs (DMARDs) during the 12 months after initial inflammatory arthritis (IA) diagnosis. METHODS We identified Veterans with incident IA diagnosed in 2007-2019. We assessed time to treatment with Kaplan-Meier curves. We identified associations between non-treatment and factors relating to patients, providers, and the health system with multivariate Generalized Estimation Equation (GEE) log-Poisson. Subgroup analyses included IA subtypes (rheumatoid arthritis [RA], psoriatic arthritis [PsA], and ankylosing spondylitis [AS]) and timeframes of the initial IA diagnosis (2007-11, 2012-15, and 2016-19). RESULTS Of 18,318 study patients, 40.7 % did not receive treatment within 12 months after diagnosis. In all patients, factors associated with non-treatment included Black race (hazard ratio, 95 % confidence interval: 1.13, 1.08-1.19), Hispanic ethnicity (1.14, 1.07-1.22), Charlson Comorbidity Index ≥2, (1.15, 1.11-1.20), and opiate use (1.09, 1.05-1.13). Factors associated with higher frequency of DMARD treatment included married status (0.86, 0.81-0.91); erosion in joint imaging report (HR: 0.86, 0.81-0.91); female diagnosing provider (0.90, CI: 0.85-0.96), gender concordance between patient and provider (0.91, CI: 0.86-0.97), and diagnosing provider specialty of rheumatology (0.53, CI: 0.49-0.56). CONCLUSION A high proportion of Veterans with IA were not treated with a biologic or non-biologic DMARD within one year after their initial diagnosis. A wide range of factors were associated with non-treatment of IA that may represent missed opportunities for improving the quality of care through early initiation of DMARDs.
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Affiliation(s)
- Jessica A Walsh
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States.
| | - Shaobo Pei
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Swetha Alexander
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Tawnie Braaten
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Jodi H Walker
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Jerry Clewell
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Kevin M Douglas
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Gopi K Penmetsa
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Xiangyang Ye
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Brian Breviu
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Grant W Cannon
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Gary A Kunkel
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
| | - Brian C Sauer
- Division of Rheumatology, Salt Lake City Veterans Affairs Health, 500 Foothill Dr, Salt Lake City, UT 84148, United States
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Sheahan A, Anjohrin S, Suruki R, Stark JL, Sloan VS. Opioid use surrounding diagnosis and follow-up in patients with ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis: Results from US claims databases. Clin Rheumatol 2024; 43:1897-1907. [PMID: 38658403 PMCID: PMC11111565 DOI: 10.1007/s10067-024-06945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/20/2024] [Accepted: 03/17/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To describe patients' use of opioids in the year preceding and year following new diagnosis of ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), compared with patients without the/se diseases. METHODS This study used US IBM® MarketScan® Commercial Claims and Encounters (CCAE) and Medicaid data and included three cohorts, comprised of incident cases of AS, PsA, or RA (2010-2017). Three matched comparator patients (without the incident disease) were selected for each patient within the disease cohort. Opioid use and appropriate treatment exposure (as defined by US guideline recommendations) in the 12-month baseline and follow-up periods were evaluated using descriptive analyses. RESULTS Prevalence of claims for opioids was higher for disease cohorts vs. comparators in CCAE; 36.4% of patients with AS, 29.5% with PsA, and 44.4% with RA did not have any claim for guideline-appropriate therapy in follow-up. Prevalence of claims for opioids was also higher for disease cohorts vs. comparators in Medicaid; 30.6% of patients with AS, 36.6% with PsA, and 65.4% with RA did not have any claim for guideline-appropriate therapy in follow-up. CONCLUSIONS In patients with AS, PsA, or RA, there was high reliance on opioids at and around the time of diagnosis. Significant proportions of patients were not on appropriate treatment as defined by professional society post-diagnosis guidelines; this discordance between actual patient therapies and treatment recommendations may suggest a need for better awareness of appropriate pain management and treatment strategies in rheumatic diseases. Key Points • This study analysed opioid use among patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), and adds to current knowledge by expanding beyond assessment of opioid use at diagnosis, to the year before and after diagnosis. • Opioid use was found to be highly prevalent in AS, PsA, and RA in the year prior to diagnosis and, interestingly, was still seen during the year after diagnosis. • Opioids are neither disease modifying, nor a targeted/recommended treatment for chronic autoimmune diseases. In addition to their association with significant economic costs, opioids are potentially hazardous and are not better than alternative treatments with superior safety profiles. • The reasons behind opioid prescribing patterns should be explored further to support movement to targeted therapies.
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Ozen G, Pedro S, Michaud K. Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis. Ann Rheum Dis 2023; 82:1487-1494. [PMID: 37460169 DOI: 10.1136/ard-2023-224339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/03/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Assess major adverse cardiovascular event (MACE) risk with opioids compared with non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA) METHODS: We conducted a new-user active comparator cohort study among patients with RA within FORWARD, The National Databank for Rheumatic Diseases, with ≥1 year participation between 1998 and 2021. Each opioid initiator was matched to two NSAID initiators by propensity scores (PSs). Patients were followed until the occurrence of the composite endpoint of MACE (myocardial infarction, stroke, heart failure, cardiovascular disease (CVD) death, venous thromboembolism (VTE)) and all-cause mortality. The risk of outcomes was estimated using Cox proportional hazards with adjustment for PS weights and imbalanced covariables. RESULTS Among 6866 opioid initiators and 13 689 NSAID initiators, 212 vs 253 MACE (20.6/1000 person-years (PY) vs 18.9/1000 PY) and 144 vs 150 deaths (13.5/1000 PY vs 10.8/1000 PY) occurred, respectively. The risk of MACE with opioids was similar to NSAIDs (HR=1.02, 95% CI 0.85 to 1.22), whereas all-cause mortality with opioids was 33% higher than NSAIDs (HR=1.33, 95% CI 1.06 to 1.67) in PS-weighted models. Among the individual outcomes of MACE, VTE risk tended to be higher in opioid initiators than NSAID initiators (HR=1.41, 95% CI 0.84 to 2.35). Strong opioids had a higher risk for all-cause mortality and VTE than weak opioids compared with NSAIDs suggesting a dose-dependent association. CONCLUSION Opioids had similar MACE risk compared with NSAIDs in patients with RA with increased all-cause mortality and likely VTE, which suggests that opioids are not safer than NSAIDs, as clinicians have perceived.
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Affiliation(s)
- Gulsen Ozen
- Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Kaleb Michaud
- Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
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Madsen C, Korona-Bailey J, Janvrin ML, Schoenfeld AJ, Koehlmoos TP. Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1133-1137. [PMID: 37280084 PMCID: PMC10546480 DOI: 10.1093/pm/pnad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.
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Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Jessica Korona-Bailey
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Miranda Lynn Janvrin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA 02115, United States
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Albuquerque CP, Reis APMG, Vargas Santos AB, Bértolo MB, Júnior PL, Neubarth Giorgi RD, Radominski SC, Guimarães MFBR, Bonfiglioli KR, L Cunha Sauma MDF, Pereira IA, Brenol CV, Henrique Mota LM, Santos-Neto L, Castelar Pinheiro GR. Do it fast! Early access to specialized care improved long-term outcomes in rheumatoid arthritis: data from the REAL multicenter observational study. Adv Rheumatol 2023; 63:17. [PMID: 37095556 DOI: 10.1186/s42358-023-00301-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 04/12/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Early rheumatoid arthritis (RA) offers an opportunity for better treatment outcomes. In real-life settings, grasping this opportunity might depend on access to specialized care. We evaluated the effects of early versus late assessment by the rheumatologist on the diagnosis, treatment initiation and long-term outcomes of RA under real-life conditions. METHODS Adults meeting the ACR/EULAR (2010) or ARA (1987) criteria for RA were included. Structured interviews were conducted. The specialized assessment was deemed "early" when the rheumatologist was the first or second physician consulted after symptoms onset, and "late" when performed afterwards. Delays in RA diagnosis and treatment were inquired. Disease activity (DAS28-CRP) and physical function (HAQ-DI) were evaluated. Student's t, Mann-Whitney U, chi-squared and correlation tests, and multiple linear regression were performed. For sensitivity analysis, a propensity score-matched subsample of early- vs. late-assessed participants was derived based on logistic regression. The study received ethical approval; all participants signed informed consent. RESULTS We included 1057 participants (89.4% female, 56.5% white); mean (SD) age: 56.9 (11.5) years; disease duration: 173.1 (114.5) months. Median (IQR) delays from symptoms onset to both RA diagnosis and initial treatment coincided: 12 (6-36) months, with no significant delay between diagnosis and treatment. Most participants (64.6%) first sought a general practitioner. Notwithstanding, 80.7% had the diagnosis established only by the rheumatologist. Only a minority (28.7%) attained early RA treatment (≤ 6 months of symptoms). Diagnostic and treatment delays were strongly correlated (rho 0.816; p < 0.001). The chances of missing early treatment more than doubled when the assessment by the rheumatologist was belated (OR 2.77; 95% CI: 1.93, 3.97). After long disease duration, late-assessed participants still presented lower chances of remission/low disease activity (OR 0.74; 95% CI: 0.55, 0.99), while the early-assessed ones showed better DAS28-CRP and HAQ-DI scores (difference in means [95% CI]: -0.25 [-0.46, -0.04] and - 0.196 [-0.306, -0.087] respectively). The results in the propensity-score matched subsample confirmed those observed in the original (whole) sample. CONCLUSIONS Early diagnosis and treatment initiation in patients with RA was critically dependent on early access to the rheumatologist; late specialized assessment was associated with worse long-term clinical outcomes.
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Affiliation(s)
- Cleandro Pires Albuquerque
- Rheumatology Service, Universidade de Brasília (UnB), Brasília, DF, Brazil.
- Universidade de Brasília / UnB, Campus Darcy Ribeiro, Brasília, CEP 70910-900, Federal District, Brazil.
| | | | - Ana Beatriz Vargas Santos
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | | | - Paulo Louzada Júnior
- School of Medicine, Universidade de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Rina Dalva Neubarth Giorgi
- Instituto de Assistência Médica ao Servidor Público Estadual, Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo, SP, Brazil
| | | | | | | | | | - Ivânio Alves Pereira
- Rheumatology, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Claiton Viegas Brenol
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Jain A, Joseph S, James J, James TS, Kumar K, Raza K, Greenfield S, Shenoy P. Delay in diagnosis of rheumatoid arthritis: reasons and trends over a decade. Rheumatol Int 2023; 43:503-508. [PMID: 35996027 DOI: 10.1007/s00296-022-05187-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Delay in diagnosis and treatment initiation often lead to poorer outcomes in rheumatoid arthritis (RA). Most of the data on delay in diagnosis and management are from western population with no data from India. Additionally, with improved health care services, whether the delay has changed over years is not known. In this longitudinal observational study, we investigated delay to diagnosis and disease-modifying antirheumatic drugs (DMARDs) initiation over past 9 years. METHODS Patients aged ≥ 18 years having RA fulfilling 2010 ACR/EULAR criteria were enrolled from January to June in years 2012, 2017 and 2021. Diagnoses received before presenting to clinic, socioeconomic status, educational level and other demographic variables were recorded. RESULTS Each year, 323 patients (mean age 49.5-52.01 years) were enrolled. There was a significant reduction in delay in diagnosis from a median (IQR) of 36 (12-84, range 1-288) months in 2012 to 12 (4-36, range 1-180) months in 2017 and 10 (5-24, range 1-120) months) in 2021 (p < 0.0001). A significant improvement in time to initiating DMARDs from 2012 [48 (24-96) months] to 2017 [12 (6-36) months] (p < 0.0001) and from 2017 to 2021 [12 (5-24) months] (p = 0.03) was seen. Higher education, more patients opting for treatment from rheumatologists, and urbanisation contributed significantly to improvement in delay. There was no impact of age or gender on delay. CONCLUSION Delay in diagnosis has improved significantly between 2012 and 2021. However, delay still remains long as most patients miss the 3-month therapeutic window. Future work focussing on reasons for delays in the patient pathway could help improve consultation pathways in India.
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Affiliation(s)
- Avinash Jain
- Department of Clinical Immunology & Rheumatology, SMS Medical College and Hospital, Jaipur, India
| | - Sanjana Joseph
- Department of Clinical Immunology & Rheumatology, Centre for Arthritis and Rheumatism Excellence (CARE), 16/554-2, NH 47, Nettoor, Cochin, Kerala, 682040, India
| | - Jeenamol James
- Department of Clinical Immunology & Rheumatology, Centre for Arthritis and Rheumatism Excellence (CARE), 16/554-2, NH 47, Nettoor, Cochin, Kerala, 682040, India
| | - Tintus Sara James
- Department of Clinical Immunology & Rheumatology, Centre for Arthritis and Rheumatism Excellence (CARE), 16/554-2, NH 47, Nettoor, Cochin, Kerala, 682040, India
| | - Kanta Kumar
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Padmanabha Shenoy
- Department of Clinical Immunology & Rheumatology, Centre for Arthritis and Rheumatism Excellence (CARE), 16/554-2, NH 47, Nettoor, Cochin, Kerala, 682040, India.
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de Albuquerque CP, Reis APMG, Santos ABV, Bértolo MB, Júnior PL, Giorgi RDN, Radominski SC, Resende Guimarães MFB, Bonfiglioli KR, da Cunha Sauma MDFL, Pereira IA, Brenol CV, da Mota LMH, Santos-Neto L, Castelar Pinheiro GR. Decreasing delays in the diagnosis and treatment of rheumatoid arthritis in Brazil: a nationwide multicenter observational study. Adv Rheumatol 2023; 63:3. [PMID: 36747307 DOI: 10.1186/s42358-022-00265-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/07/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Management delays imply worse outcomes in rheumatoid arthritis (RA) and, therefore, should be minimized. We evaluated changes in diagnostic and treatment delays regarding RA in the last decades in Brazil. METHODS Adults fulfilling the ACR/EULAR (2010) criteria for RA were assessed. Delays in diagnosis and treatment, and the frequencies of early management initiation within thresholds (windows of opportunity) of 3, 6, and 12 months from symptoms onset were evaluated. The Mann-Kendall trend test, chi-squared tests with Cramer's V effect sizes and analysis of variance were conducted. RESULTS We included 1116 patients: 89.4% female, 56.8% white, mean (SD) age 57.1 (11.5) years. A downward trend was found in diagnostic (tau = - 0.677, p < 0.001) and treatment (tau = - 0.695, p < 0.001) delays from 1990 to 2015. The frequency of early management increased throughout the period, with ascending effect sizes across the 3-, 6-, and 12-month windows (V = 0.120, 0.200 and 0.261, respectively). Despite all improvements, even in recent years (2011-2015) the diagnostic and treatment delays still remained unacceptably high [median (IQR): 8 (4-12) and 11 (5-17) months, respectively], with only 17.2% of the patients treated within the shortest, 3-month window. CONCLUSION The delays in diagnosis and treatment of RA decreased during the last decades in Brazil. Improvements (effect sizes) were greater at eliminating extreme delays (≥ 12 months) than in attaining really short management windows (≤ 3 months). Very early treatment was still an unrealistic goal for most patients with RA.
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Affiliation(s)
- Cleandro Pires de Albuquerque
- Rheumatology Service, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, Brasília, DF, 70910-900, Brazil.
| | | | - Ana Beatriz Vargas Santos
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | | | - Paulo Louzada Júnior
- School of Medicine, Universidade de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Rina Dalva Neubarth Giorgi
- Instituto de Assistência Médica ao Servidor Público Estadual, Hospital do Servidor Público Estadual de São Paulo (IAMSPE), São Paulo, SP, Brazil
| | | | | | | | | | - Ivânio Alves Pereira
- Department of Rheumatology, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Claiton Viegas Brenol
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Licia Maria Henrique da Mota
- Rheumatology Service, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, Brasília, DF, 70910-900, Brazil
| | - Leopoldo Santos-Neto
- Rheumatology Service, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, Brasília, DF, 70910-900, Brazil
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Taylor-Williams O, Inderjeeth CA, Almutairi KB, Keen H, Preen DB, Nossent JC. Total Hip Replacement in Patients with Rheumatoid Arthritis: Trends in Incidence and Complication Rates Over 35 Years. Rheumatol Ther 2022; 9:565-580. [PMID: 34997912 PMCID: PMC8964887 DOI: 10.1007/s40744-021-00414-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/09/2021] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Advances in rheumatoid arthritis (RA) management have made disease remission achievable. We evaluated trends in total hip replacement (THR) and postoperative outcomes in patients with RA in Western Australia (WA) over more than three decades. METHODS This was a retrospective analysis of routinely collected prospective data from a state-wide registry containing longitudinally linked administrative health data based on International Classification of Diseases (ICD) diagnostic and procedural codes. We included patients with two or more diagnostic codes for RA (between 1980 and 2015) and studied THR incidence rates (THR IR) and complication rates (revision, peri-prosthetic fracture, infection, venous thrombosis, and mechanical loosening). Survival rates were estimated by Kaplan-Meier method and predictors analyzed by Cox regression. RESULTS We followed 9201 RA patients over 111,625 person-years, during which 1560 patients (16.9%) underwent THR. From 1985 to 2015, THR IR (per 1000 RA patient-years) decreased from 20.8 (95% CI 20.1-21.5) to 7.3 (95% CI 7.2-7.5), and 5-year THR-free survival increased from 84.3 to 95.3% (1980-2015). Ten-year prosthetic survival was 91.2%. Complication rates in the first 5 years post-THR decreased significantly from 13.1 to 3.7% (p < 0.001). Mechanical complications such as loosening and periprosthetic fracture rates decreased significantly (> 35%, P < 0.05), while infection and revision did not change over the observation period (p > 0.05). CONCLUSIONS Over the last 30 years in RA patients, THR IR and mechanical complication rates decreased significantly, but the medical complication of infection has not changed significantly.
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Affiliation(s)
- Owen Taylor-Williams
- Rheumatology Group, Medical School, University of Western Australia, 35 Stirling Highway (M503), Perth, WA, Australia
| | - Charles A Inderjeeth
- Rheumatology Group, Medical School, University of Western Australia, 35 Stirling Highway (M503), Perth, WA, Australia
- Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Khalid B Almutairi
- Rheumatology Group, Medical School, University of Western Australia, 35 Stirling Highway (M503), Perth, WA, Australia
| | - Helen Keen
- Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Department of Rheumatology, Fiona Stanley Hospital, Perth, WA, Australia
| | - David B Preen
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Johannes C Nossent
- Rheumatology Group, Medical School, University of Western Australia, 35 Stirling Highway (M503), Perth, WA, Australia.
- Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.
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Anastasiou C, Yazdany J. Review of publications evaluating opioid use in patients with inflammatory rheumatic disease. Curr Opin Rheumatol 2022; 34:95-102. [PMID: 35044328 PMCID: PMC8974237 DOI: 10.1097/bor.0000000000000868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW This article discusses publications assessing the prevalence, efficacy, and safety of opioid analgesics in patients with rheumatic diseases, including rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, and systemic sclerosis. RECENT FINDINGS Recent studies show long-term opioid use is common in patients with inflammatory rheumatic disease. We did not find any studies demonstrating improved function or pain control with long-term opioid use in people with rheumatic diseases. Some data shows potential adverse effects including increased risk for fractures and opioid poisoning hospitalizations. There is evidence demonstrating an association of opioid use with mental health disorders, fibromyalgia, obesity, and disability, although causative links have not been established. Only minimal reductions in opioid use were observed after initiation of biologic disease modifying antirheumatic drugs (DMARDs). Studies have shown delayed DMARD initiation and reduced DMARD use in patients on opioids, raising concerns that these analgesics may delay care or initially mask symptoms of active disease. SUMMARY Available literature highlights high levels of opioid use in people with rheumatic disease, without scientific evidence to support efficacy for chronic pain control and increasing evidence of adverse events. These findings strongly suggest that opioids do not have a routine role in the chronic management of inflammatory rheumatic diseases.
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Affiliation(s)
- Christine Anastasiou
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, California, USA
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Ochola B, Nankabirwa J, Buwembo W, Kaddumukasa M, Mayanja-Kizza H. The Clinical Presentation and Factors Associated with Disease Severity of Rheumatoid Arthritis in Uganda: A Cross-Sectional Study. Open Access Rheumatol 2022; 14:75-86. [PMID: 35535352 PMCID: PMC9078424 DOI: 10.2147/oarrr.s361454] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Rheumatoid arthritis (RA) is a chronic, debilitating disease that leads to joint destruction and disability if left untreated. Few studies on RA have been conducted in Uganda, and there is limited information on disease severity and associated factors. This study sought to characterize the clinical presentation and to determine disease severity and the factors associated with disease severity among participants with RA in Uganda. Methods Between August 2018 and February 2019, patients presenting to the rheumatology outpatient clinic in Mulago National Referral Hospital were enrolled into the study using a cross-sectional design. Participants' demographics and clinical characteristics were collected using a study questionnaire, and laboratory results were extracted from their charts. The patients' functionality was assessed using the Modified Health Assessment Questionnaire and their disease severity was assessed using the RA Disease Activity Score based on 28-joint count (DAS28). Results A total of 170 participants were enrolled, of whom 81.2% were female. Nearly two-thirds (111/170) were classified as having severe disease. Having a functional status score of >0.5 (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.2, p<0.001) was significantly associated with severe disease. Conclusion In this population, the majority of the patients seen at the rheumatology outpatient clinic had severe disease, suggesting that patients may be presenting late, with limited early detection of the disease. Impaired functional status was associated with increased disease severity and may be used by clinicians to highlight disease severity when it is not possible to assess the RA DAS28.
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Affiliation(s)
- Ben Ochola
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joaniter Nankabirwa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Buwembo
- Department of Anatomy, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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11
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Sánchez-Flórez JC, Seija-Butnaru D, Valero EG, Acosta CDPA, Amaya S. Pain Management Strategies in Rheumatoid Arthritis: A Narrative Review. J Pain Palliat Care Pharmacother 2021; 35:291-299. [PMID: 34623946 DOI: 10.1080/15360288.2021.1973647] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Rheumatoid Arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation and progressive deterioration of the joints, which generates pain and stiffness. The origin of this pain is multifactorial, with inflammation, secondary osteoarthritis, as well as central and peripheral sensitization playing important roles in the development. Up to 90.4% of RA patients visit a health professional for severe pain, and despite new therapies and sophisticated treatments, there are a limited number of options for analgesic management. We conducted a narrative review using the Medline and Pubmed search engines for articles in English and Spanish between 2000 and 2021, with the keywords "pain," "rheumatoid arthritis," "non-steroidal anti-inflammatory drugs" (NSAIDs), "opioids," "glucocorticoids," "disease modifying antirheumatic drugs" (DMARDs), "neuromodulators," "antidepressants," and "cannabinoids." The articles describing epidemiology, pathophysiological considerations and current treatments were selected after a screening process carried out by the authors. It was found that DMARDs are the fundamental basis of treatment, since the main mechanism of pain in this entity is inflammation. Nonetheless, a significant number of patients continue to have pain despite optimal treatment. The available evidence for pain management in RA is scarce, however, medications such as NSAIDs, topical capsaicin, weak opioids, and treatments such as joint infiltrations or surgical management, play an important role in its management. We believe more research efforts are needed to optimize analgesic treatment recommendations, however, based on the current existing evidence, we propose a stepwise algorithm in order to properly approach these cases. Key PointsRA is a systemic autoimmune disease characterized by chronic inflammation, in which the main symptom is pain.Pain in RA is multifactorial, with inflammation, secondary osteoarthritis, as well as central and peripheral sensitization playing determining roles.DMARDs are the mainstay of RA treatment, although many patients continue to experience pain despite optimal management.Medications such as glucocorticoids, NSAIDs, topical capsaicin, and weak opioids are key elements when achieving analgesia in RA.Other pharmacological groups such as neuromodulators, antidepressants, muscle relaxants and cannabinoids currently do not have enough evidence to be recommended.
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Affiliation(s)
- Juan Camilo Sánchez-Flórez
- Juan Camilo Sánchez-Flórez, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Daniela Seija-Butnaru, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Edmundo Gónima Valero, MD, Anesthesiologist, Fellow in Pain Management and Palliative Care Medicine, Chief of the Pain and Palliative Care Department, Hospital Militar Central, Bogotá, Colombia; Claudia del Pilar Acosta Acosta, MD, Anesthesiologist, Hospital Militar Central, Universidad del Rosario - Fundación Cardioinfantil, Bogotá, Colombia; Sebastian Amaya, MS, 6th Year Medical Student, Anesthesiology and Critical Care Interest Group UEB, Universidad El Bosque Colombian School of Medicine, Bogotá, Colombia
| | - Daniela Seija-Butnaru
- Juan Camilo Sánchez-Flórez, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Daniela Seija-Butnaru, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Edmundo Gónima Valero, MD, Anesthesiologist, Fellow in Pain Management and Palliative Care Medicine, Chief of the Pain and Palliative Care Department, Hospital Militar Central, Bogotá, Colombia; Claudia del Pilar Acosta Acosta, MD, Anesthesiologist, Hospital Militar Central, Universidad del Rosario - Fundación Cardioinfantil, Bogotá, Colombia; Sebastian Amaya, MS, 6th Year Medical Student, Anesthesiology and Critical Care Interest Group UEB, Universidad El Bosque Colombian School of Medicine, Bogotá, Colombia
| | - Edmundo Gónima Valero
- Juan Camilo Sánchez-Flórez, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Daniela Seija-Butnaru, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Edmundo Gónima Valero, MD, Anesthesiologist, Fellow in Pain Management and Palliative Care Medicine, Chief of the Pain and Palliative Care Department, Hospital Militar Central, Bogotá, Colombia; Claudia del Pilar Acosta Acosta, MD, Anesthesiologist, Hospital Militar Central, Universidad del Rosario - Fundación Cardioinfantil, Bogotá, Colombia; Sebastian Amaya, MS, 6th Year Medical Student, Anesthesiology and Critical Care Interest Group UEB, Universidad El Bosque Colombian School of Medicine, Bogotá, Colombia
| | - Claudia Del Pilar Acosta Acosta
- Juan Camilo Sánchez-Flórez, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Daniela Seija-Butnaru, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Edmundo Gónima Valero, MD, Anesthesiologist, Fellow in Pain Management and Palliative Care Medicine, Chief of the Pain and Palliative Care Department, Hospital Militar Central, Bogotá, Colombia; Claudia del Pilar Acosta Acosta, MD, Anesthesiologist, Hospital Militar Central, Universidad del Rosario - Fundación Cardioinfantil, Bogotá, Colombia; Sebastian Amaya, MS, 6th Year Medical Student, Anesthesiology and Critical Care Interest Group UEB, Universidad El Bosque Colombian School of Medicine, Bogotá, Colombia
| | - Sebastian Amaya
- Juan Camilo Sánchez-Flórez, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Daniela Seija-Butnaru, MD, Resident, Pain Management and Palliative Care Department, Hospital Militar Central, Universidad de La Sabana - Instituto Nacional de Cancerología, Bogotá, Colombia; Edmundo Gónima Valero, MD, Anesthesiologist, Fellow in Pain Management and Palliative Care Medicine, Chief of the Pain and Palliative Care Department, Hospital Militar Central, Bogotá, Colombia; Claudia del Pilar Acosta Acosta, MD, Anesthesiologist, Hospital Militar Central, Universidad del Rosario - Fundación Cardioinfantil, Bogotá, Colombia; Sebastian Amaya, MS, 6th Year Medical Student, Anesthesiology and Critical Care Interest Group UEB, Universidad El Bosque Colombian School of Medicine, Bogotá, Colombia
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12
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Kowalec K, Carney H, Patel M, Hitchon C, Bolton JM, Patten SB, Graff LA, Bernstein CN, Peschken C, Marrie RA. Prevalence and Risk Factors of Substance Use Disorder in Rheumatoid Arthritis. ACR Open Rheumatol 2021; 3:889-896. [PMID: 34582128 PMCID: PMC8672171 DOI: 10.1002/acr2.11339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022] Open
Abstract
Objective In this study, we aimed to determine the lifetime prevalence of substance use disorder (SUD) in a Canadian rheumatoid arthritis (RA) cohort and factors associated with SUD in RA. Methods Participants with RA (N = 154) were recruited via rheumatology clinics as part of a larger cohort study of psychiatric comorbidity in immune‐mediated inflammatory diseases. SUD is defined as the uncontrolled use of a substance despite the harmful consequences of its use. To identify lifetime SUD, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was administered to participants. Participants’ sociodemographic and RA clinical characteristics were also assessed. We examined factors associated with lifetime SUD using unadjusted and adjusted logistic regression modeling. Results Twenty‐three (14.9%) of 154 participants with RA met the criteria for a lifetime diagnosis of SUD. The majority of the participants were women, were White, had postsecondary education, and were on a disease‐modifying antirheumatic drug. Factors associated with increased odds of SUD were male sex (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 1.03‐12.73), younger age (aOR: 0.94, 95% CI: 0.90‐0.98), and ever smoking (aOR: 6.44, 95% CI: 1.53‐27.07). Conclusion We found that approximately 1 in 7 individuals with RA had a lifetime diagnosis of SUD, highlighting the importance of identifying and treating SUD in those with RA. In particular, the following factors were associated with higher odds of SUD: male sex, younger age, and smoking behaviors.
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Affiliation(s)
- Kaarina Kowalec
- University of Manitoba, Winnipeg, Manitoba, Canada, and Karolinska Institutet, Solna, Sweden
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13
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Pazmino S, Verschueren P, Westhovens R. Does opioid-based pharmacotherapy have a place in rheumatoid arthritis therapy? Expert Opin Pharmacother 2021; 22:1945-1947. [PMID: 34129419 DOI: 10.1080/14656566.2021.1940136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- S Pazmino
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Belgium
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14
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Abstract
PURPOSE OF REVIEW Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms. RECENT FINDINGS At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA. SUMMARY Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.
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Affiliation(s)
| | - Beth I Wallace
- University of Michigan Medical School
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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15
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Taylor-Williams O, Nossent J, Inderjeeth CA. Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades. Rheumatol Ther 2020; 7:685-702. [PMID: 33000421 PMCID: PMC7695804 DOI: 10.1007/s40744-020-00238-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/19/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Over the past several decades, management of rheumatoid arthritis (RA) has evolved significantly, but few studies have examined the real-world impact of these changes on orthopaedic surgery in patients with RA. This systematic review assessed total hip arthroplasty (THA) incidence and postoperative complication rates across the past four decades. METHODS This is a systematic literature review sourcing data on THA in patients with RA from the electronic databases MEDLINE, EMBASE, Scopus, and Cochrane between January 1, 1980 and December 31, 2019. RESULTS The search retrieved 1715 articles of which 44 were included for quantitative synthesis. The rate for THA decreased by almost 40% from 11/1000 patient years (PY) in the 2000s to 7/1000 PY in the 2010s, while the overall complication rate decreased from 9.9% in the 1990s to 5.3% in the 2010s. Throughout the duration of the study, THA incidence and overall complication rate decreased. However, not all individual complication rates decreased. For example, revision and periprosthetic fracture decreased, infection and aseptic loosening remained constant, and dislocation increased. CONCLUSION Medical management of patients with RA has reduced the need for THA, while postoperative medical and surgical management has improved some postoperative outcomes. Nevertheless, there remains room for further improvement to postoperative outcomes through RA-specific management.
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Affiliation(s)
| | - Johannes Nossent
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
| | - Charles A Inderjeeth
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
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16
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Walsh JA, Pei S, Penmetsa GK, Sauer BC, Patil V, Walker JH, Clewell J, Douglas KM, Clegg DO, Cannon GW, Halwani A. Treatment Patterns with Disease-Modifying Antirheumatic Drugs in U.S. Veterans with Newly Diagnosed Rheumatoid Arthritis, Psoriatic Arthritis, or Ankylosing Spondylitis. J Manag Care Spec Pharm 2019; 25:1218-1228. [PMID: 31663467 PMCID: PMC10398041 DOI: 10.18553/jmcp.2019.25.11.1218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Delays in treatment for inflammatory arthritis (IA) are associated with unfavorable outcomes, including impaired quality of life, irreversible joint damage, and disability. OBJECTIVE To characterize treatment initiation patterns in veterans with newly diagnosed rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). METHODS ICD-9/10-CM codes and natural language processing were used to identify incident cases of RA, PsA, or AS between January 1, 2007, and December 31, 2015, in patients enrolled in the Veterans Health Administration. Patterns of treatment initiation and nontreatment with disease-modifying antirheumatic drugs (DMARDs) were assessed in the 12-month follow-up period after the incident diagnosis. Outcomes included the percentage of veterans treated with a DMARD, the mean time to the initial DMARD after diagnosis, and the percentage of veterans who accessed rheumatology care before DMARD initiation. To assess outcomes over time, veterans were grouped by year of initial IA diagnosis. Additionally, outcomes were compared between nonbiologic and biologic DMARDs and among IA subtypes (RA, PsA, and AS). Groups were statistically compared with 95% confidence intervals. RESULTS The population consisted of 12,118 IA veterans (9,711 RA, 1,472 PsA, and 935 AS), with 91.3% males and a mean age of 63.7 years. The percentage of veterans treated with ≥ 1 DMARD (nonbiologic or biologic) during the 12-month follow-up period increased from 48.8% in 2007 to 66.4% in 2015. In veterans diagnosed with IA in 2015, DMARD treatment was more common for PsA patients (72.9%) and RA patients (68.6%) than for AS patients (28.9%). In the subset treated with a DMARD within 12 months after diagnosis, the mean time to the initial DMARD after diagnosis did not change throughout the observation period (35.5 days for RA, 43.9 days for PsA, and 59.5 days for AS). Rheumatology specialty care was accessed by 87.4% of veterans treated with a nonbiologic DMARD and 92.2% of veterans treated with a biologic DMARD, in patients diagnosed in 2015. CONCLUSIONS DMARD treatment rates during the initial 12 months after diagnosis increased between 2007 and 2015, but nontreatment remained common, particularly in veterans with AS. The time to treatment after diagnosis was stable over time; it was shortest for RA, intermediate for PsA, and longest for AS. DMARD treatment was uncommon in veterans who did not access rheumatology specialty care. DISCLOSURES AbbVie Pharmaceuticals and Marriott Daughters Foundation funded this study via investigator-initiated grants. Data analyses were completed by investigators independent of AbbVie and Marriott Daughters Foundation. Walker, Clewell, and Douglas are employed by, and stockholders in, Abbvie. Halwani reports grants from BMS, Kyowa Hakko Kirin, Seattle Genetics, Roche-Genentech, Miragen, Immunedesign, Takeda, Amgen, Pharmacyclics, and Abbvie. The other authors have nothing to disclose.
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Affiliation(s)
- Jessica A. Walsh
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Shaobo Pei
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Gopi K. Penmetsa
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Brian C. Sauer
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Vikas Patil
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | | | | | | | - Daniel O. Clegg
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Grant W. Cannon
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Ahmad Halwani
- Division of Hematology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
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