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Background: Prescribing patterns in Rheumatoid Arthritis have evolved over recent decades. There is now clear evidence that combination DMARDs and biologics can acheive better disease control. This is guided by the treat to target initiative aiming for remission in all patients.
Objectives: We have used observational data to determine changes in prescribing patterns since 1996. We set out to describe the % of patients with RA being treated with individual DMARDs, combination therapy, systemic steroids and biologics.
Methods: Our study included 1492 RA patients attending two rheumatology centres. They comprised four groups of clinic attenders attending between 1996 and 2013. We collected data on the use of DMARDs, systemic steroids and biologics. Data were also collected on the proportion of patients not receiving any immunosuppressive therapy.
Results: More patients received immunosuppressive treatment with 14% of all RA patients and 16% of intermediate disease activity group not on any treatment in 2012-13 compared with 32% and 23% in the 1996-97 cohort. Methotrexate remains the most frequently prescribed DMARD across all cohorts, however the more contemporaneous cohorts have higher exposure to hydroxychloroquine, sulfasalazine and leflunomide. Conversely, few patients (<1%) were prescribed azathioprine, penicillamine and gold in 2009-10 and 2012-13 compared to earlier cohorts.
The % of patients treated with combination therapy has increased, however almost half of patients remain on a single DMARD (46%). The proportion of patients treated with biologics has steadily increased from 0 to 1996-97, 4% in 2001-03 to 17% and 21% in the two later cohorts. Systemic steroid use has fluctuated over time, prescribed in 14% in 2012-13.
1996-97 2001-03 2009-10 2012-13 N=189 N=312 N=304 N=687 No suppressive treatment 61 (32%) 59 (19%) 24 (11%) 98 (14%) One DMARD 114(60%) 197 (63%) 177 (58%) 316 (46%) Two DMARDs 1 (1%) 25 (8%) 41 (14%) 172 (25%) Three DMARDs 0 7 (2%) 24 (8%) 58 (8%) Methotrexate 30 (16%) 150 (48%) 173 (57%) 375 (54%) Sulfasalazine 30 (16%) 48 (14%) 61 (20%) 189 (27%) Hydroxychloroquine 3 (2%) 17 (5%) 63 (21%) 203 (29%) Leflunomide 0 12 (4%) 28 (9%) 58 (8%) Gold 33 (18%) 15 (5%) 3 (1%) 4 (<1%) Penicillamine 14 (8%) 12 (4%) 0 0 Other DMARDs 2 (1%) 19 (3%) 3 (1%) 2 (4%) Biologics 0 12 (4%) 52 (17%) 148 (21%) Systemic steroids 23 (12%) 71 (23%) 29 (10%) 99 (14%)
Conclusions: Increasing numbers of patients are being treated with immunosuppression. The choice of DMARD has changed from fewer patients being prescribed gold, penicillamine and azathioprine, to more patients being treated with methotrexate, hydroxychloroquine, sulfasalazine and leflunomide. Whilst the uptake of combination DMARD therapy and biologics has increased, approximately half of patients remain on a single DMARD only. This may be due to a number of reasons including physician choice, patient choice and drug intolerance. Further research is needed to explore this issue. There are still patients not on immunosuppression, suggesting that we are not treating to target, and not achieving tighter targeted control in all patients. Further research into why patients who have not achieved remission are not being treated with combination therapy is needed. The role of biologics in moderate disease activity patients to further try and achieve remission needs to be explored.
Disclosure of Interest: None declared
DOI: 10.1136/annrheumdis-2014-eular.5399