Major Injury Risk for Rheumatoid Arthritis Patients Using DMARDs

Patients with moderate rheumatoid arthritis (RA) taking disease-modifying anti-rheumatic drugs (DMARDs) have a similar risk of joint fracture that requires surgery as RA patients with high disease activity, according to a presentation at the European League Against Rheumatism Annual Congress (EULAR 2015) in Rome, Italy earlier this summer.

Researchers from St Albans City Hospital in the United Kingdom analyzed orthopedic surgeries as a surrogate marker for joint destruction and failure in more than 2,000 RA patients. The patients included in the review remained at different disease activity levels beginning at their disease onset. The researchers organized the joint interventions into categories — major (mainly large joint replacements), intermediate (for example: synovectomies, joint fusions, and excision arthroplasties of the wrist/ hand, foot), or minor (mainly soft tissue surgery).

Nearly all of the patients included had at least 2 drug activity state (DAS) recorded between year 1 and 5 of onset disease: about a fifth were in remission, 15 percent were in the low DAS range, a quarter were in the low/ moderate DAS, a fifth were in the high/ moderate DAS, and a fifth were in high DAS categories.

After adjusting for a myriad of variables, including age at disease onset, gender, recruitment year, symptom duration, baseline rheumatoid factor, BMI, HAQ, erosions and hemoglobin, patients in the low/ moderate DAS, high/ moderate DAS, and high DAS categories all were predictive of an increased risk of major joint surgery, the researchers determined.

“It is well established that sustained high disease activity in RA results in worse outcomes,” said lead author Dr. Elena Nikiphorou in a press release. “In reality, however, many treated RA patients remain in low or moderate disease activity states and their outcomes, especially in the long term, are less well studied. Our data provide an argument for updating existing disease activity cut off points to allow RA patients with moderate disease activity to receive a biological agent in addition to conventional DMARDs.”

Another important note the researchers highlighted was that with respect to intermediate injury, only high/ moderate DAS and high DAS groups predicted a higher risk than patients with low/ moderate DAS or low DAS.

The findings underline that the risk of injury requiring joint surgery is high for patients with both moderate and severe RA, instead of only severe RA patients, as previously thought. The researchers noted that in some countries, additional treatment with biological DMARDs are based on a disease activity cut off that would exclude RA patients with moderate disease activity.