Abstract
To the Editor,
Over the past two decades, the treatment of Rheumatoid Arthritis (RA) has shifted toward aggressive management consisting of early initiation of disease-modifying antirheumatic drugs (DMARDs) coupled with close monitoring and dose adjustments to achieve optimal disease control classically referred to as ‘Treat to Target’ approach. The objective proof of this approach of earlier diagnosis and aggressive treatment resulting in better disease control and reduced incidence of accrual joint damage has been shown in data published from developed countries.1–4 Looking at the diverse socio-economic determinants of the outcome of RA patients, there is a lack of similar decade-trend analysis from the Indian population showing the objective benefit of this approach.
To compare the trends, in 2016, we cross-sectionally studied 100 consecutive patients with RA visiting a rheumatology clinic in a tertiary private hospital in Mumbai, with respect to their baseline clinical characteristics, treatment, and radiographic details. We compared our findings with those of a similar cross-sectional study published in 1995 from the same centre. We compared our findings from 2016 with those of patients with RA treated in 1995 5 and looked for significant differences in treatment approaches and baseline joint damage. To maintain homogeneity, we used the preliminary classification criteria of the American College of Rheumatology (1987) for RA diagnosis in both cohorts.
A comparison of patients in each cohort, as shown in Table 1, provides a detailed analysis of the demographic, clinical, laboratory, and radiological characteristics of both groups. The important differences were that patients in the 2016 cohort were referred early compared to those in the 1995 cohort and assessed early in the course of the disease. In fact, 40% of patients in the 2016 cohort had already received a rheumatology consultation before visiting our tertiary centre, indicating an increased availability of rheumatology services and improved patient awareness. Most of these patients were DMARD-naïve, probably because of the early referral to a rheumatologist. This study also highlights the treatment differences between the two cohorts. In the 2016 cohort, more patients were taking a combination of DMARDs and newer molecules, while fewer patients were using oral steroids. Importantly, none of the patients in the 2016 cohort received gold or D-penicillamine therapy, suggesting a shift toward more effective and safer treatment options.
Comparison of Demographic, Clinical, Serological, Treatment, and Radiographic Characteristics in Rheumatoid Arthritis Patients: 1995 Versus 2016 Cohorts.
aX-rays of both hands with wrists (PA view) were done at baseline. A total of 26 joints were studied per patient, that is, eight PIP, two IP (thumb), 10 MCP, two carpals, two radio carpal and two radioulnar joints. The two IP joints were read along with the PIP joints. N = (26 joint each patient × Number of patients 00) = 26×100 = 2,600.
bConventional DMARDS - Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide and glucocorticoids.
Radiological evaluation of the patients revealed that the 2016 cohort had significantly better radiological profiles than the 1995 cohort. This can be attributed to the fact that patients in the 2016 cohort were seen earlier by rheumatologists, and a significant proportion were already under the care of a rheumatologist, leading to early intervention, better treatment, and minimisation of joint damage.
Overall, this comparative study of RA patients two decades apart underscores the positive effects of early referral to rheumatologists, increased patient awareness, and the use of newer and more effective treatment options to improve outcomes in RA patients. This underscores the importance of timely diagnosis, aggressive management, and regular rheumatologic care to reduce the patient burden of RA in terms of joint damage, deformity, and disability.
While this study, conducted within a single tertiary healthcare centre with a modest sample size in a metropolitan area, provides valuable insights, its scope for generalisation is limited. Nonetheless, it underscores the significance of early referrals to specialised centres, improved medical training, and heightened public awareness as avenues for enhancing the care of patients with RA. Additionally, our findings justify the current modern-day approach to RA management, which emphasises early and aggressive management strategies, such as treat-to-target, resulting in a positive outcome with lesser joint damage and deformity.
Footnotes
Author Contribution
All the authors have participated sufficiently in the intellectual content, conception, design of this work, analysis and interpretation of the data, as well as the writing of the manuscript, and have agreed to take public responsibility for it to have listed as a contributor.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval
The ethical committee approval number is 885-14-CB-(MRC). The same has been attached as supplementary material.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.