GUEPARD treat-to-target strategy is significantly more efficacious than ESPOIR routine care in early rheumatoid arthritis according to patient-reported outcomes and physician global estimate

Objective. To analyse seven RA Core Data Set measures and three indices for their capacity to distinguish treatment results in early RA in the GUEPARD treat-to-target clinical trial vs ESPOIR routine care.

Methods.Post hoc analyses compared 65 GUEPARD and 130 matched control ESPOIR patients over 6 and 12 months for mean changes in measures, relative efficiencies and standardized response means (SRM). Three indices—28-joint disease activity score (DAS28), clinical disease activity index (CDAI) and routine assessment of patient index data (RAPID3)—were compared for mean changes and numbers of patients with high, moderate or low activity or remission using κ values.

Results. Greater improvement was seen for GUEPARD vs ESPOIR, statistically significant for physician and patient global estimates and pain and health assessment questionnaire physical function (HAQ-FN), but not joint counts and laboratory tests. Relative efficiencies with tender joint count as the referent measure indicated that pain (2.57) and global estimates by patient (3.13) and physician (2.31) were most efficient in distinguishing GUEPARD from ESPOIR. Mean improvements in GUEPARD vs ESPOIR were −3.4 vs −2.6 for DAS28 (0–10) (24%), −29.8 vs −23.1 for CDAI (0–76) (23%) and −13.0 vs −7.8 for RAPID3 (0–30) (40%) (all P < 0.01); agreement was moderate between CDAI vs DAS28 (κ = 0.56) and vs RAPID3 (κ = 0.48), and fair between DAS28 vs RAPID3 (κ = 0.26).

Conclusion. Patient and global measures indicate greater efficacy than joint counts or laboratory measures in detecting difference between GUEPARD treat-to-target and ESPOIR routine care. A RAPID3 of only patient measures may help guide treat-to-target in busy clinical settings.

Patient self-report RADAI (Rheumatoid Arthritis Disease Activity Index) joint counts on an MDHAQ (Multidimensional Health Assessment Questionnaire) in usual care of consecutive patients with rheumatic diseases other than rheumatoid arthritis

OBJECTIVE

To analyze a patient self-report joint count from the Rheumatoid Arthritis Disease Activity Index (RADAI) on a Multidimensional Health Assessment Questionnaire (MDHAQ) in a cohort of consecutive patients seen in usual rheumatology care with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), psoriatic arthritis (PsA), and gout.

METHODS

Each patient completed an MDHAQ, which included a RADAI, at each visit in one usual care setting. In order to include a physician measure, a random visit at which there was a recorded physician global estimate was selected for each of 465 patients (174 patients with RA, 75 with SLE, 113 with OA, 53 with PsA, and 50 patients with gout). The RADAI was analyzed for total scores (range 0-48), number of involved joint groups (range 0-16), and each specific joint group, and then compared in the 5 diagnostic groups to one another and to other MDHAQ measures and the Routine Assessment of Patient Index Data 3 (RAPID3).

RESULTS

In patients with RA, SLE, OA, PsA, and gout, mean RADAI scores (range 0-48) were 12.4, 6.5, 10.1, 6.7, and 2.7, respectively. The mean numbers of involved joint groups (range 0-16) were 6.9, 3.8, 4.8, 4.5, and 1.7, respectively, and the median numbers were 6, 2, 4, 4, and 1, respectively. RADAI scores were correlated significantly with the physician global estimate, except in SLE, and at higher levels with the MDHAQ and RAPID3 scores in all diagnostic groups.

CONCLUSION

The RADAI self-report joint counts can be used to record self-report involvement of specific joints and joint groups in patients with SLE, OA, PsA, and gout, with minimal effort on the part of the rheumatologist.

Can remission in rheumatoid arthritis be assessed without laboratory tests or a formal joint count? possible remission criteria based on a self-report RAPID3 score and careful joint examination in the ESPOIR cohort

OBJECTIVE

To explore 5 possible criteria for remission in rheumatoid arthritis (RA) based on a patient self-report index, the Routine Assessment of Patient Index Data (RAPID3), with a careful joint examination and possible physician global estimate (DOCGL), but without a formal joint count or laboratory test.

METHODS

The ESPOIR early RA cohort of 813 French patients recruited in 2002-2005 was analyzed to identify patients in remission 6 months after enrollment, according to 2 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria: Boolean ≤ 1 for total tender joint count-28, swollen joint count-28, C-reactive protein, and patient global estimate (PATGL), and Simplified Disease Activity Index (SDAI) ≤ 3.3. Agreement with 7 other remission criteria was analyzed - Disease Activity Score-28 (DAS28) ≤ 2.6, Clinical Disease Activity Index (CDAI) ≤ 2.8, and 5 candidate criteria based on RAPID3, joint examination, and DOCGL: "RAPID3R" (RAPID3 ≤ 3.0); "RAPID3R+SJ1" (RAPID3 ≤ 3.0, ≤ 1 swollen joint); "RAPID3R+SJ1+D1" (RAPID3 ≤ 3.0, ≤ 1 swollen joint, DOCGL ≤ 1); "RAPID3R+SJ0" (RAPID3 ≤ 3.0, 0 swollen joints); and "RAPID3R+SJ0+D1" (RAPID3 ≤ 3.0, 0 swollen joints, DOCGL ≤ 1), according to kappa statistics, sensitivity, and specificity. Residual global, articular, and questionnaire abnormalities according to each criteria set were analyzed.

RESULTS

Among 813 ESPOIR patients, 720 had complete data to compare all 9 possible criteria. Substantial agreement with the Boolean criteria was seen for SDAI, CDAI, RAPID3R+SJ1, RAPID3R+SJ1+D1, RAPID3R+SJ0, and RAPID3R+SJ0+D1 (92.2%-94.7%, kappa 0.67-0.79), versus only moderate agreement for DAS28 or RAPID3R (79.9%-85.8%, kappa 0.46-0.55).

CONCLUSION

Remission according to CDAI and RAPID3R+SJ1, but not DAS28 or RAPID3R, is similar to that of the ACR/EULAR criteria. RAPID3 scores require a complementary careful joint examination for clinical decisions, do not preclude formal joint counts or other indices, and may be useful in busy clinical settings.

American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials

OBJECTIVE

Remission in rheumatoid arthritis (RA) is an increasingly attainable goal, but there is no widely used definition of remission that is stringent but achievable and could be applied uniformly as an outcome measure in clinical trials. This work was undertaken to develop such a definition.

METHODS

A committee consisting of members of the American College of Rheumatology, the European League Against Rheumatism, and the Outcome Measures in Rheumatology Initiative met to guide the process and review prespecified analyses from RA clinical trials. The committee requested a stringent definition (little, if any, active disease) and decided to use core set measures including, as a minimum, joint counts and levels of an acute-phase reactant to define remission. Members were surveyed to select the level of each core set measure that would be consistent with remission. Candidate definitions of remission were tested, including those that constituted a number of individual measures of remission (Boolean approach) as well as definitions using disease activity indexes. To select a definition of remission, trial data were analyzed to examine the added contribution of patient-reported outcomes and the ability of candidate measures to predict later good radiographic and functional outcomes.

RESULTS

Survey results for the definition of remission suggested indexes at published thresholds and a count of core set measures, with each measure scored as 1 or less (e.g., tender and swollen joint counts, C-reactive protein [CRP] level, and global assessments on a 0-10 scale). Analyses suggested the need to include a patient-reported measure. Examination of 2-year followup data suggested that many candidate definitions performed comparably in terms of predicting later good radiographic and functional outcomes, although 28-joint Disease Activity Score-based measures of remission did not predict good radiographic outcomes as well as the other candidate definitions did. Given these and other considerations, we propose that a patient's RA can be defined as being in remission based on one of two definitions: (a) when scores on the tender joint count, swollen joint count, CRP (in mg/dl), and patient global assessment (0-10 scale) are all ≤ 1, or (b) when the score on the Simplified Disease Activity Index is ≤ 3.3.

CONCLUSION

We propose two new definitions of remission, both of which can be uniformly applied and widely used in RA clinical trials. We recommend that one of these be selected as an outcome measure in each trial and that the results on both be reported for each trial.

Efficacy and safety of methotrexate in combination with other non-biologic disease-modifying antirheumatic drugs (DMARDs) in treatment of rheumatoid arthritis

Methotrexate (MTX) is well-established as the "anchor drug" for patients with rheumatoid arthritis (RA), to be used early and aggressively, with higher long-term effectiveness, tolerability, and safety than any other disease-modifying antirheumatic drug (DMARD). However, about 20% to 40% of patients experience incomplete responses to MTX and require further therapy, with options including other non- biologic DMARDs, low dose glucocorticoids, and biologic agents. Non-biologic DMARDs in combination with MTX may provide similar efficacy to a biologic agent in clinical trials, with fewer adverse events and lower costs. This re- view presents a summary of 21 clinical trials documenting the efficacy and safety of MTX in combination with other non-biologic DMARDs.

Evidence that the strategy is more important than the agent to treat rheumatoid arthritis. Data from clinical trials of combinations of non-biologic DMARDs, with protocol-driven intensification of therapy for tight control or treat-to-target

Eight major "strategy trials" in rheumatoid arthritis (RA) are reviewed, with protocol-driven escalation of combinations of methotrexate and other small molecule non-biological disease modifying antirheumatic drugs (DMARDs). All documented the value of intensive treatment adjusted according to quantitative data, generally a disease activity score (DAS) or its 28 joint count version (DAS28). Three of the 8 trials, TICORA, Dutch DAS-driven care, and CAMERA, may be termed "pure strategy trials," to com- pare a protocol-driven "intensive" strategy to usual care. Five other trials, BeSt, CIMESTRA, TICORA 2, Step-down versus step-up, and TEAR, may be termed "hybrid trials," in which an initial parallel design was supplemented with incremental protocol-driven intensification of treatment. A strategy of aiming for low disease activity or remission appears more important than the specific agent used. In group data, the proportion of good responses seen in these trials with combinations of non-biologic, small molecule DMARDs are comparable to data from clinical trials of biological agents although responses appear more rapid with biological agents, and certain individual patients may require a biologic agent for adequate control. These trials also illustrate the value of a quantitative index, monitored frequently for rational intensification of therapy. The data make a compelling case for both routine monitoring with a quantitative index and consideration of routine adjustment of therapy at each visit. Combinations of methotrexate with other non-biologic DMARDs and glucocorticoids, toward a target of low disease activity or remission, may improve outcomes for patients with RA at levels similar to biologic agents in many patients.

Update on methotrexate as the anchor drug for rheumatoid arthritis

Methotrexate has become the "anchor drug" for rheumatoid arthritis (RA), taken by many more patients than any other disease modifying anti-rheumatic drug (DMARD) or biological agent. Methotrexate has greater efficacy and effectiveness than any other non-biologic DMARD, and greater tolerability and safety than other DMARDs. The efficacy of methotrexate is comparable to biologic agents in parallel clinical trials of DMARD-naïve patients. Adequate responses to methotrexate monotherapy or combinations with other non-biologic DMARDs are seen in about two- thirds of patients with RA in usual care. The most efficacious treatments for RA reported in the rheumatology literature are seen in strategy trials with methotrexate as the anchor drug, without any biologic agent. Interpretation of significantly lower radiographic progression between methotrexate and biologic agents in clinical trials is over- stated regarding clinic consequences. The admonition to patients to refrain entirely from consumption of alcohol while taking methotrexate may be unnecessary. Accurate information concerning methotrexate as the anchor drug for RA should lead to better understanding of optimal use and better to patient outcomes in usual clinical care.

RAPID3, an index of only 3 patient self-report core data set measures, but not ESR, recognizes incomplete responses to methotrexate in usual care of patients with rheumatoid arthritis

OBJECTIVE

To perform a longitudinal cohort study concerning the capacity of prospectively-collected erythrocyte sedimentation rates (ESR) and scores for physical function, pain, patient global estimate, and routine assessment of patient index data (RAPID3) on a multidimensional health assessment questionnaire (MDHAQ), to recognize incomplete versus adequate responses to methotrexate in rheumatoid arthritis (RA) in one usual care setting, prior to description of RAPID3.

METHODS

All patients were seen in one academic setting, in which MDHAQ scores were collected in all patients at all visits in the infrastructure of care. ESR was collected in all RA patients. All 93 RA patients in whom methotrexate was initiated between 1996 and 2001 with available 5-year follow-up were analyzed. "Incomplete response" was defined as initiation of subsequent biological therapy and "adequate response" as no biological therapy over 5 years. Measures were analyzed at the baseline methotrexate visit and at a subsequent visit: in 30 "incomplete responders" when biological therapy was prescribed; and in 63 "adequate responders 2.6 years after methotrexate initiation (mean interval to biological therapy in "incomplete responders").

RESULTS

ESR fell similarly by 33% to 36% in both groups. MDHAQ scores fell by 56% to 79% over 2.6 years in adequate responders but increased by 0% to 31% in incomplete responders. Median RAPID3 fell from 10.6 to 3.6 (low severity=3.1 to 6, remission≤3) in adequate responders and rose from 14.9 to 16.2 (high severity>12) in incomplete responders.

CONCLUSION

RAPID3, but not ESR, recognizes incomplete versus adequate methotrexate responses in usual clinical care, and may be useful in busy usual care settings.

Importance of patient history and physical examination in rheumatoid arthritis compared to other chronic diseases: results of a physician survey

OBJECTIVE

To survey physicians' opinions concerning the relative importance of 5 clinical encounter components-vital signs, patient history, physical examination, laboratory tests, and ancillary studies-in the diagnosis and management of 8 chronic diseases.

METHODS

A SurveyMonkey internet survey was e-mailed to 7,265 US physicians, including 3,542 rheumatologists and 3,723 nonrheumatologists, with the following query: "Please indicate the relative importance of 5 sources of information-vital signs, patient history, physical examination, laboratory tests, and ancillary studies-in diagnosis of congestive heart failure (CHF), diabetes mellitus, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, rheumatoid arthritis (RA), and ulcerative colitis." The response options were 0-20%, 21-40%, 41-60%, 61-80%, and 81-100%. A second query with an identical structure addressed management of the 8 diseases. The proportions of physicians who estimated each component as most (or tied for most) important in diagnosis or in management were computed.

RESULTS

The survey was completed by 313 physicians (154 rheumatologists and 159 nonrheumatologists). More than 90% estimated vital signs as most important for hypertension, and laboratory tests for diabetes mellitus and hypercholesterolemia. More than 70% estimated ancillary studies as most important for lymphoma, pulmonary fibrosis, and ulcerative colitis. Patient history and physical examination were estimated as most important for RA and CHF by ≥50% of nonrheumatologists.

CONCLUSION

RA and CHF were the only 2 of the 8 diseases studied for which ≥50% of nonrheumatologists estimated a patient history and physical examination as most important for diagnosis and management. Confirmation and extension of these observations in actual care may have implications for reimbursement and organization of clinical care.

Treat-to-target: not as simple as it appears

Treat-to-target as a strategy for rheumatoid arthritis (RA) is now widely advocated based on strong evidence. Nonetheless, implementation of treat-to-target raises caveats, as is the case with all clinical care strategies. The target of remission or even low disease activity does not apply to all individual patients, some of whom are affected by concomitant fibromyalgia, other comorbidities, joint damage, and/or who simply prefer to maintain current status and avoid risks of more aggressive therapies. No single universal 'target' measure or index exists for all individual RA patients. An emphasis in most studies on radiographic progression, rather than physical function or mortality, as the most important outcome to document the value of treat-to-target may be inappropriate. Many reports imply that the only limitation to treating all RA patients with biological agents involves costs, ignoring effective results in most patients with methotrexate and other disease-modifying anti-rheumatic drugs (DMARDs) and adverse events associated with biological agents. Indeed, the best outcomes in reported RA clinical trials result from tight control with DMARDs, rather than from biological agents, as does better overall status of RA patients at this time compared to previous decades. Pharmacoeconomic reports may ignore that RA patients are older, less educated, and have more comorbidities than the general population, as well as critical differences in patient status according to the gross domestic product of different countries. While treating to a target of remission or low disease activity, including with biological agents, is appropriate for many patients, awareness of these concerns could improve implementation of treat-to-target for optimal care of all RA patients.

Will shared decision making between patients with chronic musculoskeletal pain and physiotherapists, osteopaths and chiropractors improve patient care?

BACKGROUND

Chronic musculoskeletal pain (CMP) is treated in primary care by a wide range of health professionals including chiropractors, osteopaths and physiotherapists.

AIMS

To explore patients and chiropractors, osteopaths and physiotherapists' beliefs about CMP and its treatment and how these beliefs influenced care seeking and ultimately the process of care.

METHODS

Depth interviews with a purposive sample of 13 CMP patients and 19 primary care health professionals (5 osteopaths, 4 chiropractors and 10 physiotherapists).

RESULTS

Patients' models of their CMP evolved throughout the course of their condition. Health professionals' models also evolved throughout the course of their treatment of patients. A key influence on patients' consulting behaviour appeared to be finding someone who would legitimate their suffering and their condition. Health professionals also recognized patients' need for legitimation but often found that attempts to explore psychological factors, which may be influencing their pain could be construed by patients as delegitimizing. Patients developed and tailored their consultation strategies throughout their illness career but not always in a strategic fashion. Health professionals also reflected on how patients' developing knowledge and changing beliefs altered their expectations. Therefore, overall within our analysis, we identified three themes: 'the evolving nature of patients and health professionals models of understanding CMP'; 'legitimating suffering' and 'development and tailoring of consultation and treatment strategies throughout patients' illness careers'.

CONCLUSIONS

Seeking care for any condition is not static but a process particularly for long-term conditions such as CMP. This may need to be taken into account by both CMP patients and their treating health professionals, in that both should not assume that their views about causation and treatment are static and that instead they should be revisited on a regular basis. Adopting a shared decision-making approach to treatment may be useful particularly for long-term conditions; however, in some cases, this may be easier said than done due to both patients' and health professionals' sometimes discomfort with adopting such an approach. Training and support for both health professionals and patients may be helpful in facilitating a shared decision-making approach.