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Early RA Medical Therapy May Prevent Need for Surgery


 

SAN DIEGO — Patients in the Utrecht Rheumatoid Arthritis Cohort who began treatment early in the course of disease were less likely to need joint surgery later on, Dr. Suzan M.M. Verstappen said at the annual meeting of the American College of Rheumatology.

In the ongoing Utrecht cohort study, begun in 1990, patients initially were randomized to early treatment with methotrexate, intramuscular gold, or hydroxychloroquine—or to a “pyramid” treatment approach, which was at that time the traditional paradigm. In the pyramid strategy patients first take aspirin and other NSAIDs, delaying treatment with the disease-modifying antirheumatic drugs (DMARDs), until later in the course of disease.

At the time of the first analysis, in 1994, it was apparent that patients in the early DMARD group were faring better, and henceforth, all patients were randomized to one of the three drugs, she said.

“In the present study we investigated the prevalence of joint surgery and looked at which clinical, radiographic, and demographic variables in the first 2 years of treatment—when we all know a lot of disease activity occurs—predicted later joint surgery,” said Dr. Verstappen of University Medical Center Utrecht (the Netherlands).

The cohort included 482 patients, whose mean age was 56 years and mean disease duration was 7.2 years. A total of 70% were female, and 65% were rheumatoid factor positive.

Overall, 144 patients underwent a total of 256 surgeries. Of these interventions, 32% were major surgeries such as total joint replacement, 50% were intermediate procedures such as arthrodesis, and 18% were minor interventions such as arthroscopy.

By the end of the fifth year, about 18% of patients had required at least one type of surgical intervention, according to Kaplan-Meier survival analysis. Overall mean survival time until surgery was 10 years, and for the major surgical interventions, the mean survival time was 12 years.

With regard to the need for surgical intervention among patients who responded to drug therapy, compared with those who were nonresponders, at the end of the first year no significant difference was seen between the two groups, but by the end of the second year, patients who responded to drug therapy had fewer surgical interventions, she said.

Furthermore, surgical interventions were significantly more common in those whose functional disability was worse at baseline and those who initially were randomized to NSAID therapy.

Multivariate Cox regression analyses of the 1-year data found that female gender, delayed start with DMARDs, and radiographic progression were predictive of later surgery. Hazard ratios for these variables were 1.55, 1.68, and 1.016, respectively, Dr. Verstappen said.

At the end of the second year, only a delayed start of DMARD therapy and radiographic progression were predictors, with hazard ratios of 1.73 and 1.029, respectively, on the multivariate analysis.

The need for joint surgery can be considered an outcome measure reflecting an unfavorable course of rheumatoid arthritis, and a significant number of patients still require some type of surgical intervention, Dr. Verstappen said.

“This is the first study to demonstrate that early treatment prevents later surgical intervention, and we hope that with more early aggressive treatment the percentage of patients requiring surgery later on will decrease further,” she said.

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