在真實世界中觀察目標治療策略實施1年對初診RA患者的影響

在真實世界中觀察目標治療策略實施1年對初診RA患者的影響

Tan AL, et al. Rheumatology 2016.Present ID: 083.

              

背景:制訂目標治療(T2T)建議是要將得到RA優化結局的治療策略告知風溼病醫師和患者,這些策略構建於偱證和專家意見。本文報道的真實世界前瞻性觀察對RA患者進行了12個月以上的隨訪,以評估T2T治療策略對初診RA患者的影響。

方法:自2012年4月,英國國家健康服務體系(NHS)提供風溼病診療服務的48家機構登記了初診RA患者,之前瞻性觀察的形式對T2T治療策略進行審計。患者在門診隨診時採集有關疾病管理、治療和結局評估的數據。這裏咱們介紹隨訪≥12個月的分析結果。

結果:截至2015年8月,共有1470例患者錄入審計系統,從初診至分析截止日隨訪≥12個月的共有460例(31%)。

在這個隊列,發病時年齡(中位數, IQR)爲61歲, 32%爲男性。74%(342/460)患者在疾病診斷時就將臨牀緩解目標(DAS28 < 2.6)設定爲治療目標, 7%(33/460)的患者將低度活動度(LDA, DAS28: 2.6 - 3.2)設定爲治療目標。分析可用數據顯示,45%(135/301)的患者在每次訪問時都評估和記錄DAS28。在設定治療目標的患者中,緩解組210/342例、LDA組21/33例同時擁有基線和第12個月的DAS28評估數據。一年裏平均隨訪次數爲4次(SD: 3.1)。

12個月後,接受DMARD單藥、兩藥聯合、三藥聯合治療的患者例數分別爲56%(182/325)、35%(114/325)和5%(15/325)。臨牀緩解和LDA達標率分別爲56%(182/325)和29%(6/21)。12個月時,緩解目標組和LDA目標組的DAS28均值(中位數)分別爲2.38和3.89。

持續緩解率爲21%患者(51/248),持續緩解的定義爲連續3次隨訪均爲臨牀緩解。其中, 59%(30/51)接受單藥治療, 39%(20/51)接受兩藥聯合治療,無患者接受三藥聯合治療。知足使用生物製劑條件(連續2次隨訪的DAS> 5.1,且2種DMARDs治療失敗)的患者比例爲9%(42/460),其中處方了一種生物製劑的患者比例爲45%(19/42)。

在年齡小於60歲的患者羣中,受僱傭工做率在基線時爲57%(125/221),隨訪12個月時爲46%(77/169)。在年齡≥60歲的患者中,基線和隨訪12個月時的受僱傭率分別爲8%(19/239)和4%(7/156)。報告「工做時有難度」的患者比例由基線時的40%(34/84)降低至12月時的16%(8/49)。

結論:在RA初診時設立臨牀緩解爲治療目標的患者中,經12個月治療達到臨牀緩解的患者比例超過50%。然而,儘管應用了T2T策略,在實現持續緩解方面還有待進一步完善。其中值得注意的是, DAS28評估次數相對較低, DMARDs三聯療法不多在初診後12個月給予,適合使用生物製劑的患者卻未處方生物製劑。將來應該經過與傳統治療策略比較對僱傭的影響,以明確目標治療策略(T2T)對於RA患者而言的社會價值。

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原文連接或參見如下信息。

THE IMPACT OF TREAT TO TARGET ON 1 YEAR REAL WORLD OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS

 

Ai Lyn Tan¹, Maya Buch¹, David O'Reilly², Tom Sheeran³, Sarah Keidel⁴, Sarang Chitale⁵, Paul Emery¹

¹Leeds Musculoskeletal Biomedical Research Unit, The Leeds Teaching Hospitals Trust, Leeds, UNITED KINGDOM, ²Rheumatology Department, West Suffolk Hospital, Bury St Edmunds, UNITED KINGDOM, ³Rheumatology Department, Cannock Chase Hospital, Cannock, UNITED KINGDOM, ⁴Medical, Abbvie Ltd, Maidenhead, UNITED KINGDOM, ⁵Rheumatology Department, Peter Maddison Rheumatology Centre, Llandudno, UNITED KINGDOM.

 

Background: Treat to Target (T2T) recommendations are designed to inform rheumatologists and patients about strategies to enable optimal outcomes in rheumatoid arthritis (RA) based on evidence and expert opinion. This real world, prospective audit has a patient cohort with >12 months’ follow up data allowing assessment of the impact of T2T.

Methods: Since April 2012, 48 NHS rheumatology services have enrolled newly diagnosed RA patients prospectively into the T2T audit. Data on disease management, treatments and outcomes are collected when the patient is reviewed in clinic. Here we present results of a cohort of patients who have been followed up for 12 months from diagnosis.

Results: By August 2015, 1470 patients had been enrolled into the audit, with a cohort of 460(31%) with data at ≥12 months from diagnosis.

Within this cohort, median (IQR) age at symptom onset was 61 years, 32% male. 74%(342/460) had a target of remission (Disease Activity Score [DAS]28 <2.6 ) and 7%(33/460) had a target of low disease activity state (LDAS, DAS28 2.6-<3.2) set at diagnosis. Where data were available, 45%(135/301) had DAS28 performed at each visit. 210/342 patients with a DAS28 remission target, and 21/33 with a LDAS target, had both baseline and 12 month DAS28. Mean (SD) number of visits over a year was 4(3.1).

After 12 months, 56%(182/325), 35%(114/325) and 5%(15/325) of patients were on DMARD mono, dual and triple therapy, respectively. 117/210(56%) achieved remission and 6/21(29%) achieved LDAS. The median (IQR) DAS28 score achieved was 2.38 and 3.89 in the remission and LDAS groups, respectively.

21%(51/248) of patients were in sustained remission (3 consecutive visits) at 1 year. Of these, 59%(30/51) received monotherapy, 39%(20/51) dual and 0%(0/51) triple therapy. 9%(42/460) of patients were eligible for a biologic (2 consecutive DAS scores >5.1, failure of 2 DMARDS); of these, 45%(19/42) were prescribed a biologic.

Among the cohort of patients aged <60years, the % in employment changed from 57%(125/221) at baseline to 46%(77/169) at 12 months. Among those aged ≥60 years, 8%(19/239) and 4%(7/156) were employed at baseline at 12 months respectively. There was a reduction in patient reported work difficulties from 40%(34/84) at baseline to 16%(8/49) at 12 months.

Conclusion: Greater than 50% of patients in the remission target group were in remission by 12 months; however, despite the T2T approach, there is still an unmet need in terms of achieving sustained remission. This is highlighted by relatively low numbers of DAS28 assessments, triple therapy rarely being introduced before 12 months, and the proportion of biologic eligible patients not receiving them. It would be interesting to compare the employment data against a cohort treated with conventional strategies to determine the societal and patient impact of T2T in RA.