Assessing the progression of joint damage in rheumatoid arthritis

Effects of use of specialty services on disease-modifying antirheumatic drug use in the treatment of rheumatoid arthritis in an insured elderly population

BACKGROUND

In community settings, disease-modifying antirheumatic drug (DMARD) use for rheumatoid arthritis (RA) falls short of treatment recommendations. This population-based study investigates the relationship between the use of DMARDs and specialty care in an insured population.

METHOD

A cohort of individuals aged 65 or older with RA was identified from a population-based physician billing database in Ontario, Canada, together with information on visit rates to general and specialist physicians and visit-specific diagnoses. DMARD prescription data were obtained from the Ontario Drug Benefits Plan database. The proportions of individuals with RA using DMARDs and specialist care were calculated for the 43 counties in Ontario, and the relationship between the 2 was determined using logistic multilevel modeling, controlling for possible confounders.

RESULTS

A total of 13,698 RA individuals aged 65 or older were identified, representing 1% of the 65-or-older population. Within this cohort, 58% received DMARDs and 68% made 1 or more RA-related visits to a specialist in 3 years. There was considerable variation by county in both the proportion of those with RA making visits to specialists (39-82 per 100 RA population) and receiving DMARDs (36-81%). The use of DMARDs was significantly associated with the use of specialist services by individuals with RA (odds ratio 1.9 [95% confidence interval 1.87, 1.88] for counties with highest versus lowest proportional use of specialists) independent of effects of age, sex, income, and comorbidities.

CONCLUSION

Even in a universally funded setting, suboptimal treatment of RA is associated with lack of access to specialist services. These findings are likely applicable to many jurisdictions worldwide.

Disease modification in rheumatoid arthritis with special reference to cyclosporin A

Disease modifying antirheumatic drugs improve clinical markers of synovial inflammation as well as acute phase reactants and functional status in patients with rheumatoid arthritis. Some of the disease modifying antirheumatic drugs probably also retard radiographic progression. Data from prospective observational studies and epidemiological studies indicate a modest and temporary effect. New treatment modalities are needed, including both new strategies and new drugs. Cyclosporin A improves clinical markers of synovial inflammation and is useful for individual patients with rheumatoid arthritis. However, further studies are required to investigate the long term efficacy and tolerance of cyclosporin in rheumatoid arthritis.

Long term experience of salazopyrin EN in rheumatoid arthritis (RA)

Our studies have shown that Salazopyrin EN is an effective slow-acting anti-rheumatic drug, improving clinical synovitis, depressing the acute phase response, capable of inducing remissions and possibly influencing the progression of joint damage. It is well-tolerated in the long-term with comparatively few serious side effects. Its mechanism of action, however, is still not entirely clear. We have found that the sulphapyridine moiety penetrates the synovial membrane and also that it can modify immune function. While Salazopyrin undoubtedly has an important role in the therapy of rheumatoid arthritis, it probably also has a place in the treatment of seronegative arthropathies and the spondyloarthritides. Furthermore we suggest that it should be used as an anchor drug in combination therapy to attempt to suppress disease activity further and limit joint damage.