AB1153 ANALGESIC AND ANTI-INFLAMMATORY DRUG USE IN PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND SPONDYLOARTHRITIS VERSUS CONTROLS IN A BELGIAN GENERAL PRACTITIONER REGISTRY

Background:

Rheumatoid arthritis (RA), psoriatic arthritis (PSA) and spondyloarthritis (SPA) are the most common inflammatory rheumatic diseases. Pain is the hallmark symptom in these conditions and pain relief is ranked first amongst preferred outcomes by patients. Level of analgesic and anti-inflammatory drug use is unknown in these populations in Belgium.

Objectives:

To compare analgesic and anti-inflammatory drug use in patient populations of RA, PSA and SPA versus controls in a General Practitioners (GP) setting in an era of expanding treatment possibilities in rheumatology.

Methods:

Data were obtained from Intego over a 13-year time interval from 1999 to 2012. Intego is a Flemish GP-based morbidity registration network hosted at the Academic Center for General Practice of the KU Leuven, covering 2% of the Flemish general population. Patients classified under the International Classification of Primary Care codes L88 (rheumatoid/seropositive arthritis) and L99 (musculoskeletal disease other) were selected for this study. Experienced rheumatologists verified if the keywords mapped to these codes corresponded to a diagnosis of RA/SPA/PSA. The date of these diagnoses in Intego was considered “baseline”. Controls were matched on age, gender, baseline date and GP practice in a 4:1 case ratio. Intego registers all electronic drug prescriptions by the GP. Anytime use of glucocorticoids, NSAIDs, opioids except tramadol, tramadol and paracetamol in the first 3 years after diagnosis is presented. Proportions of patients and controls on analgesic and anti-inflammatory drugs were compared by Chi-Square analyses.

Results:

Over a 13-year period, 738, 229 and 167 patients were included with a diagnosis of RA, SPA or PSA, respectively. Table 1 presents the medication use of these populations. The three conditions had statistically significantly more prescriptions for all types of analgesic and anti-inflammatory drugs compared to controls. Approximately 70% of patients with an inflammatory rheumatic condition received mild pain medication (NSAIDs, Tramadol and Paracetamol) in the first three years after diagnosis. To note is the high use of opioids, even excluding tramadol, in these populations ranging up to 15%.

Table 1.

3-year analgesic and anti-inflammatory drug use in RA, SPA and PSA patients versus controls

MedicationRARA ControlSPASPA ControlPSAPSA ControlNumber of patients7382952229916167668Glucocorticoids241(33%)348(12%)29(13%)70(8%)47(28%)67(10%)NSAIDs455(62%)1156(39%)161(70%)340(37%)114(68%)267(40%)Opioids109(15%)263(9%)31(14%)53(6%)24(14%)45(7%)Tramadol87(12%)150(5%)22(10%)28(3%)16(10%)26(4%)Paracetamol233(32%)598(20%)63(28%)165(18%)51(31%)141(21%)Total analgesic and anti-inflammatory drug use506(69%)1409(48%)172(75%)407(44%)121(72%)309(46%)

RA= Rheumatoid arthritis, PSA= psoriatic arthritis, SPA= spondyloarthritis. Total analgesic and anti-inflammatory drug is the sum of NSAIDs, Tramadol and Paracetamol. Anytime use of drugs are presented.

Conclusion:

Frequent analgesic and anti-inflammatory drug use in patients with a chronic inflammatory joint condition is to be expected, and underlined by the results of our study. Remarkably is the high use of opioids, even excluding tramadol, in patients with RA, PSA and SPA in an era of effective disease modifiers, as well in the control population. Our data shows that around 9% of the Belgian population receives at least once over a 3-year period an opioid prescription. As our data only registers electronic GP prescriptions, this is likely to be an underestimation of the true prescription proportion. Detailed analyses on dose and duration of analgesic and anti-inflammatory drugs will follow.

Disclosure of Interests:

Sofia Pazmino: None declared, Veerle Stouten: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies, Pavlos Mamouris: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Kurt de Vlam Grant/research support from: Celgene, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Eli Lilly, Galapagos, Johnson & Johnson, Novartis, Pfizer Inc, UCB, Delphine Bertrand: None declared, Kristien Van der Elst: None declared, Bert Vaes: None declared, Diederik De Cock: None declared

THU0214 LONG-TERM EFFECTIVENESS OF METHOTREXATE WITH STEP DOWN GLUCOCORTICOID BRIDGING (COBRA SLIM) VERSUS OTHER CONVENTIONAL DMARD REGIMENS AS INITIAL RA THERAPY: 5-YEAR OUTCOMES OF THE CARERA TRIAL

Background:

The treat-to-target Care in Early Rheumatoid Arthritis (CareRA) trial demonstrated that remission induction with csDMARD combinations and step-down glucocorticoids (GCs) was not superior over methotrexate (MTX) monotherapy with step-down GCs (Cobra Slim) in RA patients with a high-risk profile (1). Moreover, Cobra Slim showed benefit over a tight step-up with MTX in monotherapy (TSU) in RA patients with a low-risk profile.

Objectives:

To compare the long term outcomes up to 5 years of different initial intensive treatment strategies in participants of the CareRA-plus study.

Methods:

In the CareRA trial, patients with DMARD naïve early RA were stratified in a high- or low-risk group based upon the presence of serummarkers, disease activity and erosive status. High-risk patients were randomised to Cobra Classic (MTX+sulphasalazine with highly dosed GC remission induction scheme), Cobra Avant-Garde (MTX+leflunomide with moderately dosed GC scheme) or Cobra Slim. Low-risk patients were randomised to Cobra Slim or TSU. Patients completing this trial were eligible for the CareRA-plus observational study. Here, patients were evaluated 6-monthly over 3 years. Therapy adaptation was left to the treating physician. Efficacy was assessed by DAS28-CRP and HAQ and compared between the originally allocated treatment arms. The 5-year evolution from CareRA baseline of DAS28-CRP and HAQ was assessed via linear mixed models. All adverse events (AEs), considered to be clinically relevant by investigators, and DMARD/GCs therapy were registered.

Results:

Of 322 eligible patients, 252 (78%) were included in CareRA-plus, of which 203 (81%) completed the study. Characteristics and outcomes at the CareRA closing visit (year 2) did not differ between patients entering CareRA-plus or not. DAS28-CRP<2.6 at year 5 in high-risk patients was 72%, 77% and 64% in the Classic, Slim and Avant-Garde group respectively (p=0.403). In the longitudinal analyses, all treatment arms in the high-risk group had comparable DAS28-CRP (p=0.921) and HAQ scores over time (p=0.540). In the low-risk population, 83% of patients in the Slim and 82% in the TSU arm had DAS28-CRP<2.6 at year 5 (p=0.945). Low-risk patients starting Cobra-Slim had lower DAS28-CRP scores over 5 years than those receiving TSU (p= 0.002). HAQ score over time did not differ (p=0.129). In high-risk patients, the total numbers of AEs throughout CareRA-plus, were 70 in 36 Classic, 95 in 48 Slim and 80 in 36 Avant-Garde patients (p=0.182). In the low-risk group there were 18 AEs in 10 Slim and 36 in 17 TSU patients (p=0.048). During the 5-year study, biologics were initiated in 22% of all patients: 23% of Classic, 23% of Slim high-risk, 25% of Avant-Garde, 17% of Slim low-risk, and 15% of TSU patients. At the year 5 visit, 71%, 61% and 50% of high-risk patients were on csDMARD monotherapy (mostly MTX) in Classic, Slim and Avant-Garde respectively. Of the low-risk group, 65% in COBRA-Slim and 62% in TSU were taking a single csDMARD. At the year 5 visit, 9% of all participants received chronic oral GC therapy (>3 months).

Conclusion:

All intensive treatment strategies resulted in excellent long-term clinical outcomes. Initial Cobra Slim therapy showed comparable 5-year effectiveness as Cobra Classic and Avant-Garde in high-risk early RA patients and better efficacy and safety than conservative step up treatment in low-risk patients.

Figure 1.

Mean disease activity by DAS28-CRP or mean functionality by HAQ index scores for high-risk or low-risk patients.

References:

[1]Stouten, V. et al. Effectiveness of different combinations of DMARDs and glucocorticoid bridging in early rheumatoid arthritis: two-year results of CareRA. Rheumatology (Oxford). (2019)doi:10.1093/rheumatology/kez213.

Disclosure of Interests: :

Veerle Stouten: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Diederik De Cock: None declared, Sofia Pazmino: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Kristien Van der Elst: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

Graded response model fit, measurement invariance and (comparative) precision of the Dutch-Flemish PROMIS® Upper Extremity V2.0 item bank in patients with upper extremity disorders

BACKGROUND

The Dutch-Flemish PROMIS® Upper Extremity (DF-PROMIS-UE) V2.0 item bank was recently developed using Item Response Theory (IRT). Unknown for this bank are: (1) if it is legitimate to calculate IRT-based scores for short forms and Computerized Adaptive Tests (CATs), which requires that the items meet the assumptions of and fit the IRT-model (Graded Response Model [GRM]);(2) if it is legitimate to compare (sub) groups of patients using this measure, which requires measurement invariance; and (3) the precision of the estimated patients' scores for patients with different levels of functioning and compared to legacy measures. Aims were to evaluate (1) the assumptions of and fit to the GRM, (2) measurement invariance and (3) (comparative) precision of the DF-PROMIS-UE v2.0.

METHODS

Cross-sectional data were collected in Dutch patients with upper extremity disorders. Assessed were IRT-assumptions (unidimensionality [bi-factor analysis], local independence [residual correlations], monotonicity [coefficient H]), GRM item fit, measurement invariance (absence of Differential Item Functioning [DIF] due to age, gender, center, duration, and location of complaints) and precision (standard error of IRT-based scores across levels of functioning). To study measurement invariance for language [Dutch vs. English], additional US data were used. Legacy instruments were the Disability of the Arm, Shoulder and Hand (DASH), the QuickDASH and the Michigan Hand Questionnaire (MHQ).

RESULTS

In total 521 Dutch (mean age ± SD = 51 ± 17 years, 49% female) and 246 US patients (mean age ± SD = 48 ± 14 years, 69% female) participated. The DF-PROMIS-UE v2.0 item bank was sufficiently unidimensional (Omega-H = 0.80, Explained Common Variance = 0.68), had negligible local dependence (four out of 1035 correlations > 0.20), good monotonicity (H = 0.63), good GRM fit (no misfitting items) and demonstrated sufficient measurement invariance. Precise estimates (Standard Error < 3.2) were obtained for most patients (7-item short form, 88.5%; standard CAT, 91.3%; and, fixed 7-item CAT, 87.6%). The DASH displayed better reliability than the DF-PROMIS-UE short form and standard CAT, the QuickDASH displayed comparable reliability. The MHQ-ADL displayed better reliability than the DF-PROMIS-UE short form and standard CAT for T-scores between 28 and 50. For patients with low function, the DF-PROMIS-UE measures performed better.

CONCLUSIONS

The DF-PROMIS-UE v2.0 item bank showed sufficient psychometric properties in Dutch patients with UE disorders.

Methotrexate in combination with other DMARDs is not superior to methotrexate alone for remission induction with moderate-to-high-dose glucocorticoid bridging in early rheumatoid arthritis after 16 weeks of treatment: the CareRA trial

Objectives

To compare the efficacy and safety of intensive combination strategies with glucocorticoids (GCs) in the first 16 weeks (W) of early rheumatoid arthritis (eRA) treatment, focusing on high-risk patients, in the Care in early RA trial.

Methods

400 disease-modifying antirheumatic drugs (DMARD)-naive patients with eRA were recruited and stratified into high risk or low risk according to classical prognostic markers. High-risk patients (n=290) were randomised to 1/3 treatment strategies: combination therapy for early rheumatoid arthritis (COBRA) Classic (methotrexate (MTX)+ sulfasalazine+60 mg prednisone tapered to 7.5 mg daily from W7), COBRA Slim (MTX+30 mg prednisone tapered to 5 mg from W6) and COBRA Avant-Garde (MTX+leflunomide+30 mg prednisone tapered to 5 mg from W6). Treatment modifications to target low-disease activity were mandatory from W8, if desirable and feasible according to the rheumatologist. The primary outcome was remission (28 joint disease activity score calculated with C-reactive protein <2.6) at W16 (intention-to-treat analysis). Secondary endpoints were good European League Against Rheumatism response, clinically meaningful health assessment questionnaire (HAQ) response and HAQ equal to zero. Adverse events (AEs) were registered.

Results

Data from 98 Classic, 98 Slim and 94 Avant-Garde patients were analysed. At W16, remission was reached in 70.4% Classic, 73.6% Slim and 68.1% Avant-Garde patients (p=0.713). Likewise, no significant differences were shown in other secondary endpoints. However, therapy-related AEs were reported in 61.2% of Classic, in 46.9% of Slim and in 69.1% of Avant-Garde patients (p=0.006).

Conclusions

For high-risk eRA, MTX associated with a moderate step-down dose of GCs was as effective in inducing remission at W16 as DMARD combination therapies with moderate or high step-down GC doses and it showed a more favourable short-term safety profile.

EudraCT number:

2008-007225-39.

A detailed analysis of treatment delay from the onset of symptoms in early rheumatoid arthritis patients

OBJECTIVES

A treatment delay of more than 12 weeks can negatively affect treatment response in rheumatoid arthritis (RA). Our aim was to quantify the different stages of delay before RA treatment in different rheumatology centres and to explore influencing factors.

METHOD

A total of 156 disease-modifying anti-rheumatic drug (DMARD)-naive early RA patients were included from eight practices: one academic hospital, five general hospitals, and two private practices. Eight different types of delay were defined from symptom onset until treatment initiation. Information on the duration of each stage of delay was collected from the patient, their general practitioner (GP), and patient files at the rheumatology practice. Patient/GP demographics and disease activity/severity parameters were recorded.

RESULTS

The median total delay from symptom onset until treatment initiation was 23 weeks whereas patient-, GP- and rheumatologist-related median delay was 10, 4, and 7 weeks, respectively. Only 21.6% of the patients had a total delay of less than 12 weeks. The total median delay in private rheumatology practices was less than in academic and general hospitals (p < 0.001). Furthermore, RA patients treated within 12 weeks of symptom onset showed a higher level of disease activity. The duration of rheumatologist-related delay was inversely correlated with disease activity parameters. Patients with morning stiffness were treated, on average, 3 weeks sooner than those without morning stiffness (p < 0.006).

CONCLUSIONS

In only one out of five early RA patients was treatment initiated within 12 weeks of symptom onset, as recommended. Patient-related delay contributed most to overall delay. Disease activity and type of rheumatology centre are pivotal determinants of delay.