scholarly journals Time to Disease-modifying Antirheumatic Drug Treatment in Rheumatoid Arthritis and Its Predictors: A National, Multicenter, Retrospective Cohort

2012 ◽  
Vol 39 (11) ◽  
pp. 2088-2097 ◽  
Author(s):  
RUBEN TAVARES ◽  
JANET E. POPE ◽  
JEAN-LUC TREMBLAY ◽  
CARTER THORNE ◽  
VIVIAN P. BYKERK ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Symptom Onset ◽  
Care Pathway ◽  
Onset Time ◽  
Musculoskeletal Condition ◽  
Inception Cohort ◽  
Time To Treatment ◽  
Kaplan Meier ◽  
Delayed Initiation ◽  
Disease Modifying

Objective.To determine the proportion of patients with rheumatoid arthritis (RA) under rheumatologic care treated with disease-modifying antirheumatic drugs (DMARD) within 6 months from symptom onset and the components of time to treatment and its predictors.Methods.A historical inception cohort of 339 patients with RA randomly selected from 18 rheumatology practices was audited. The proportion that initiated DMARD treatment within 6 months from symptom onset was estimated using Kaplan-Meier analysis. Time to each component of the care pathway was estimated. Multivariable modeling was used to determine predictors of early treatment using 12 preselected variables available in the clinical charts. Bootstrapping was used to validate the model.Results.Within 6 months from symptom onset, 41% (95% CI 36%−46%) of patients were treated with DMARD. The median time to treatment was 8.4 (interquartile range 3.8−24) months. Events preceding rheumatology referral accounted for 78.1% of the time to treatment. The most prominent predictor of increased time to treatment was a concomitant musculoskeletal condition, such as osteoarthritis or fibromyalgia. The significance of other variables was less consistent across the models investigated. Included variables accounted for 0.69 ± 0.03 of the variability in the model.Conclusion.Fewer than 50% of patients with RA are treated with DMARD within 6 months from symptom onset. Time to referral to rheumatology represents the greatest component delay to treatment. Concomitant musculoskeletal condition was the most prominent predictor of delayed initiation of DMARD. Implications of these and other findings warrant further investigation.

scholarly journals POS0287 USE OF BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RELATION TO THE RISK OF LYMPHOMA: A COHORT STUDY OF US VETERANS WITH RHEUMATOID ARTHRITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 369.1-369
Author(s):  
N. Singh ◽  
A. Peterson ◽  
A. Baraff ◽  
A. Korpak ◽  
M. Vaughan-Sarrazin ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Native American ◽  
Diagnostic Code ◽  
Health Administration ◽  
Inception Cohort ◽  
Regular User ◽  
Psoriatic Arthropathy ◽  
Disease Modifying ◽  
Us Veterans ◽  
Lymphoma Risk

Background:Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development. However, the association of the use of biologic disease modifying anti-rheumatic drugs (bDMARDs) in patients with RA on lymphoma risk needs further evaluation.Objectives:Examine the effect of administration of bDMARDS on the incidence of lymphoma in an inception cohort of RA.Methods:We identified patients diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the Veteran’s Health Administration (VHA) databases. To be included, each patient was required to meet the following criteria: 1) 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart 2) a prescription for a conventional synthetic DMARD (csDMARD) within 90 days of the first RA diagnosis 3) One inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VHA). We excluded patients for any of the following if they preceded the first RA diagnosis: 1) a prior single RA diagnostic code 2) a prescription for any DMARD medication 3) a concomitant diagnosis of another inflammatory arthritis (e.g. psoriatic arthropathy) 4) a diagnosis of lymphoma. Index date for the study is the date of the first qualifying RA diagnosis. Lymphoma diagnoses were identified through VHA records using the International Classification of Diseases-Oncology codes.Results:We identified 27,536 veterans with RA in the study period meeting the inclusion and exclusion criteria. Of these, 53% (n=14,705) were in the age range 60 to 80 years. The cohort was 89% male, 75.5% White, 13.7% African American. Over the study period, 1.2% (n=332) of the study population developed a lymphoma.Conclusion:Using the nationwide VHA we have identified a large inception cohort of patients with RA of whom 1.2% developed lymphoma over study follow-up. This data will be used in future analyses to produce estimates of the effect of biologic medications on lymphoma risk, adjusting for confounding by indication and other variables.Table 1.Baseline characteristics of the cohort based on bDMARD exposure statusCharacteristicbDMARD-naive (n= 19,095)bDMARD-exposed (n=8,441)Overall Lymphomas Age (years)171161 18-4046 40-606378 60-8010074 >8043 Males17,206 (90%)7,270 (86%)Race White14,150 (74%)6,627 (76%) Black2,674 (14%)1,090 (13%) Asian96 (0.5%)46 (0.5%) Native American or Pacific Islander371 (2%)187 (2.2%) Missing1,804 (9%)491 (6%)Acknowledgements:The work in this abstract is supported by Investigator Award from the Rheumatology Research Foundation to Dr Singh.Disclosure of Interests:None declared

scholarly journals Women’s accounts of help-seeking in early rheumatoid arthritis from symptom onset to diagnosis

2014 ◽  
Vol 10 (4) ◽  
pp. 259-272 ◽  
Author(s):  
Anne Townsend ◽  
Catherine L Backman ◽  
Paul Adam ◽  
Linda C Li
Keyword(s):  
Rheumatoid Arthritis ◽  
Narrative Analysis ◽  
Symptom Onset ◽  
Help Seeking ◽  
Care Pathway ◽  
Policy And Practice ◽  
Prompt Treatment ◽  
Gender And Health ◽  
And Gender ◽  
Depth Interviews

Background As interest in gender and health grows, the notion that women are more likely than men to consult doctors is increasingly undermined as more complex understandings of help seeking and gender emerge. While men’s reluctance to seek help is associated with practices of masculinities, there has been less consideration of women’s help-seeking practices. Rheumatoid arthritis (RA) is a chronic disease that predominantly affects women and requires prompt treatment but considerable patient-based delays persist along the care pathway. This paper examines women’s accounts of help seeking in early RA from symptom onset to diagnosis. Methods We conducted in-depth interviews with 37 women with RA <12 months in Canada. Analysis was based on a constant comparison, thematic approach informed by narrative analysis. Results The women’s accounts featured masculine practices associated with men’s help-seeking. The women presented such behaviours as relational, e.g. rooted in family socialisation and a determination to maintain roles and ‘normal’ life. Discussion Our findings raise questions about how far notions of gender operate to differentiate men and women’s help seeking and may indicate more similarities than differences. Recognising this has implications for policy and practice initiatives for both men and women.

Time to Consultation and Disease-modifying Antirheumatic Drug Treatment of Patients with Rheumatoid Arthritis — Northern Alberta Perspective

2012 ◽  
Vol 39 (4) ◽  
pp. 707-711 ◽  
Author(s):  
JALAL A. NANJI ◽  
MAY CHOI ◽  
ROBERT FERRARI ◽  
CHRISTOPHER LYDDELL ◽  
ANTHONY S. RUSSELL
Keyword(s):  
Rheumatoid Arthritis ◽  
Primary Care ◽  
Symptom Onset ◽  
Primary Care Physicians ◽  
Chart Review ◽  
Physician Practices ◽  
Diagnostic Coding ◽  
Select Group ◽  
Disease Modifying ◽  
Northern Alberta

Objective.To determine the timeliness of consultation and initiation of disease-modifying antirheumatic drugs (DMARD) in patients with rheumatoid arthritis (RA) referred to rheumatologists.Methods.The first part of the study was a review of the charts of 151 patients with RA followed by 3 rheumatologists. The outcome measure was the interval between symptom onset and consultation with a rheumatologist. The second part of the study involved a chart review of 4 family physician practices in a small urban center in order to determine the accuracy of diagnostic coding (International Classification of Diseases; ICD-9) of RA, as well as the proportion of patients with RA seen by a rheumatologist. Finally, a survey was sent to primary care physicians at a group of walk-in clinics to determine what percentage of their patients with RA were referred to a rheumatologist and, concerning referral patterns, how likely it is they would refer a confirmed or suspected RA patient to a rheumatologist.Results.Patients with RA referred to rheumatologists in this sample were seen by a rheumatologist at a mean of 9.8 months (median 5 mo, range 0–129 mo) after symptom onset, and mean 1.2 months (median 4.0 mo, range 0–8 mo) after being referred by their primary care physician. All referred patients with confirmed RA were started on DMARD within 1 week of initial consultation. Primary care physicians would refer suspected RA patients 99.5% of the time (median 100, range 90–100%), and 87.6% (median 90, range 50–100%) of patients with confirmed RA would have seen a rheumatologist at least once. A chart review showed that, in a select group of family physicians, 70.9% (22/31) of patients coded as RA per the ICD-9 did indeed have RA and all had seen a rheumatologist for their condition.Conclusion.In Northern Alberta, patients with RA are seen and started on DMARD therapy in a timely fashion. Most of the delay is at the primary care level, suggesting a need for improved education of patients and primary care physicians rather than a formal triage system.

scholarly journals Clinical Characteristics and Outcomes of Patients with Coronavirus Disease 2019-associated ARDS and the Early Intubation: A Two-Hospital Retrospective Cohort Study in Hubei, China

2021 ◽  
Author(s):  
Jing-Lan Mu ◽  
Ming-Zhe Qin ◽  
Hui-Mei Sun ◽  
Bao-Sheng Guo ◽  
Shi-Da Qiu ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Retrospective Cohort ◽  
Invasive Mechanical Ventilation ◽  
Onset Time ◽  
Oxygenation Index ◽  
Median Number ◽  
Multiple Organ ◽  
Hospital Death ◽  
Kaplan Meier ◽  
Early Intubation

Abstract Background: More evidence in understanding the heterogeneity of COVID-19-associated acute respiratory distress syndrome (ARDS) and in improving strategy to increase the survival from the critical patients intubated is always needed. The study aimed to comprehensively explore the features of COVID-19-associated ARDS and the features and outcomes between the early and late intubation groups. Methods: This retrospective cohort included 65 adult COVID-19 inpatients with ARDS at two hospitals in Hubei, China. The ARDS in these patients was diagnosed according to the Berlin criteria. We defined intubation within 7 days of ARDS diagnosis as ‘early’ intubation and that performed from the eighth day as ‘late’ intubation based on literatures. The outcomes were invasive mechanical ventilation and in-hospital death. The log-binomial regression models were used to explore the risk factors and the Kaplan-Meier statistic was used to estimate the risk of mortality. Results: The median number of days from symptom onset to ARDS diagnosis was 11.0 (IQR, 8.0–13.0). Up to 84.1% COVID-19-related ARDS patients demonstrated multiple organ injuries. The mortality rates were 41.9% and 85.7% in moderate and severe ARDS. The early intubation and the late intubation had the differences in days from symptom onset/hospital admission/ARDS diagnosis to intubation (P = 0.023, P = 0.011, P < 0.001). Compared with the early-intubation group, the late-intubation group showed less severity at admission (median oxygenation index 159.0 95% CI 134.0-203.0 vs. 133.9 95% CI 98.3-183.2), but required more aggressive therapies (ICU 80% vs. 70%, CRRT 50% vs. 10%, prone-position 50% vs. 30%, and ECMO 50% vs. 10%) and had higher risk to die at hospital (RR, 3.18; 95% CI 1.98-5.12). Conclusion: The ARDS caused by COVID-19 was not typical ARDS due to prolonged onset time, multiple organ injuries, and higher mortalities. The late-intubation group showed less severity at admission but higher risk of in-hospital death than the early-intubation group.

Time to Treatment for New Patients with Rheumatoid Arthritis in a Major Metropolitan City

2011 ◽  
Vol 38 (7) ◽  
pp. 1282-1288 ◽  
Author(s):  
SHAHIN JAMAL ◽  
SHABBIR M.H. ALIBHAI ◽  
ELIZABETH M. BADLEY ◽  
CLAIRE BOMBARDIER
Keyword(s):  
Rheumatoid Arthritis ◽  
Median Time ◽  
Sex Education ◽  
Symptom Onset ◽  
Chart Review ◽  
Key Factors ◽  
Contributing Factors ◽  
Disease Modifying Antirheumatic Drugs ◽  
Treatment Delays ◽  
Time To Treatment

Objective.To determine the proportion of patients with rheumatoid arthritis (RA) seen by rheumatologists and treated with disease-modifying antirheumatic drugs (DMARD) within 3 months of symptom onset, to determine where treatment delays occur, and to identify contributing factors.Methods.A retrospective cohort study in which adult patients with RA, diagnosed between January 1, 2003, and May 31, 2006, were recruited from rheumatologists’ offices to participate in a telephone survey and chart review. The percentage treated with DMARD within 3 months of symptom onset was determined, along with median times for delay. Factors contributing to the delay were explored using multivariable logistic regression.Results.Our study included 204 patients. Within 3 months of symptoms, 22.6% (95% CI 16.8%, 28.3%) received DMARD and within 6 months, 47.6% (95% CI 40.7%, 54.4%). The median time from symptom onset to DMARD was 6.4 months [interquartile range (IQR) 3.3, 12.0] with a median time from RA diagnosis by a rheumatologist to DMARD of 0.0 months (IQR 0.0, 1.0). Higher baseline swollen joint counts resulted in earlier treatment. Age, sex, education, comorbidity, rheumatologist practice type, and years since the physician’s graduation did not affect time to treatment.Conclusion.Fewer than 25% of patients referred to rheumatologists were treated within 3 months of symptom onset. Identification of inflammatory arthritis and referral to rheumatologists are the key factors in timely care, because once patients are seen there is no delay to treatment. Future resources should be focused on development and evaluation of interventions to facilitate rapid triage, referral, and assessment by a rheumatologist.

scholarly journals AB0141 THE DYNAMICAL TRAJECTORY OF GLUCOCORTICOIDS TAPERING AND DISCONTINUATION IN RHEUMATOID ARTHRITIS PATIENTS COMMENCING GLUCOCORTICOIDS WITH CSDMARDS: A REAL-WORLD DATA FROM 2009 TO 2020

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1098.1-1098
Author(s):  
W. Xie ◽  
H. Huang ◽  
Z. Zhang
Keyword(s):  
Rheumatoid Arthritis ◽  
Disease Activity ◽  
Real World ◽  
Real Life ◽  
Cumulative Probability ◽  
Disease Modifying Antirheumatic Drugs ◽  
Antirheumatic Drugs ◽  
Kaplan Meier ◽  
Disease Modifying

Background:Glucocorticoids (GC) are currently recommended as bridging therapy in combination with csDMARDs in rheumatoid arthritis (RA) and should be tapered as rapidly as clinically feasible for safety concerns about their long-term use [1-3].Objectives:To unravel the dynamical trajectory and characteristics of GCs tapering and discontinuation in RA patients commencing GCs with concomitant csDMARDs.Methods:We used data from longitudinal real-world TARRA (Treat-to-TARget in RA) cohort in Peking University First Hospital. RA patient who started GCs and contaminant csDMARDs therapy over 1-year follow-up were included. The changes in GCs dose and disease activity in the context of csDMARDs were evaluated. GCs discontinuation rate was analyzed using Kaplan-Meier analysis. The relapse profiles within 6 months after GCs discontinuation were also analyzed.Results:A total of 207 RA patients were included. During a median follow-up duration of 38.6 months, 124 (59.9%) patients discontinued GC. The median oral prednisolone dose of 10 (5-10) mg/d at initiation was reduced by 50% in the first 6 months and then more slowly reduced, finally to zero by 48 months. The cumulative probability of GCs discontinuation was 26.6% at year 1, 48.0% at year 2, 58.6% at year 3, with calculated median time of 27 months (Figure 1). Of the 124 patients who discontinued GCs, add of other csDMARDs or increment of current csDMARDs was required in 29.0% of them. Approximately half of 124 patients were in clinical remission at the time point of GCs discontinuation. Within 6 months after GCs withdrawal, 79.1% (91/115) of participants maintained relapse-free.Figure 1.Kaplan-Meier curve with cumulative probability of glucocorticoids discontinuation in RA patients who start glucocorticoids with concomitant csDMARDs during the follow-up period. csDMARDs: conventional synthetic disease modifying antirheumatic drugs.Conclusion:In RA patients commencing GCs in addition to csDMARDs, GCs are feasibly discontinued with favorable control of disease activity in real-life setting, mostly without short-term flare. Adding targeted therapies are sometimes required to attain GCs discontinuation within the time frame of 3 months in current guidelines.References:[1]Hoes JN, Jacobs JW, Buttgereit F, Bijlsma JW. Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis. Nat Rev Rheumatol. 2010 Dec;6(12):693-702. doi: 10.1038/nrrheum.2010.179.[2]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):685-699. doi: 10.1136/annrheumdis-2019-216655.[3]Conn DL. The Story Behind the Use of Glucocorticoids in the Treatment of Rheumatoid Arthritis. Semin Arthritis Rheum. 2020 Dec 17;51(1):15-19. doi: 10.1016/j.semarthrit.2020.09.016.Disclosure of Interests:None declared

scholarly journals Equivalent Responses to Disease-modifying Antirheumatic Drugs Initiated at Any Time During the First 15 Months After Symptom Onset in Patients with Seropositive Rheumatoid Arthritis

2010 ◽  
Vol 37 (3) ◽  
pp. 550-557 ◽  
Author(s):  
HAOLING H. WENG ◽  
VEENA K. RANGANATH ◽  
DINESH KHANNA ◽  
MYUNGSHIN OH ◽  
DANIEL E. FURST ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Symptom Onset ◽  
Radiographic Progression ◽  
Remission Rate ◽  
Linear Regression Analysis ◽  
Progression Rate ◽  
Disease Modifying Antirheumatic Drugs ◽  
Antirheumatic Drugs ◽  
Seropositive Rheumatoid Arthritis ◽  
Disease Modifying

Objective.To evaluate responses by time to initiation of nonbiologic disease-modifying antirheumatic drugs (DMARD) in a DMARD-naive cohort of patients with early seropositive rheumatoid arthritis (RA).Methods.Subjects were categorized by the time from symptom onset to the first DMARD use (median 5.7 months, range 0.6–15.9). Subjects who started their first DMARD within 5 months of symptom onset were compared to subjects who started after 5 months. Disease Activity Scores (DAS-44) and total Sharp Score (TSS) progression rates were analyzed using Wilcoxon rank-sum and chi-square tests; multiple linear regression analysis adjusted for potential covariates. The slope of the least-squares regression line was calculated to estimate the annualized TSS progression rates.Results.Of 233 RA patients, 76% were female and mean age was 50 (SD 13) years. At DMARD start, DAS-44 was similar in all subsets within the 0.6 to 15 months’ duration between symptom onset and DMARD initiation. Erosion scores tended to be higher in those who started DMARD later, but Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were higher in those who started DMARD earlier. During the 2 years after DMARD initiation, improvements in HAQ-DI and DAS-44 were similar in the various duration subsets, with about 25% ever achieving DAS remission (DAS < 1.6). Radiographic progression tended to be numerically but not statistically more rapid in the earlier subsets.Conclusion.Following initiation of nonbiologic DMARD therapy at various times within 15 months of symptom onset, improvements of DAS-44, HAQ-DI, remission rate, and radiographic progression rate were similar, although higher baseline erosion scores were present in those with later initiation of DMARD.

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