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Therapeutic Strategies in Rheumatoid Arthritis Over a 40-Year Period
HILAL MARADIT KREMERS, PAULO NICOLA, CYNTHIA S. CROWSON, W. MICHAEL O'FALLON, and SHERINE E. GABRIEL
ABSTRACT.
Methods. A population based inception cohort was assembled from among all Rochester, Minnesota, residents aged ≥ 18 years who were first diagnosed with RA (1987 American College of Rheumatology criteria) between January 1, 1955, and January 1, 1995. All subjects were followed longitudinally through their complete medical records until death, migration from Olmsted County, or date of abstraction (January 1, 2001, to January 1, 2003). Drug exposure data were collected on all DMARD and corticosteroid regimens. Time to DMARD initiation was examined using the Kaplan-Meier method. The influence of calendar time and disease characteristics on time from incidence to first DMARD therapy and the number of DMARD regimens were analyzed using Cox regression and proportional odds models, respectively. Results. The study population comprised 603 patients (73% female) with a mean age of 58 years and a mean followup of 15 years. At 2 years after RA onset, 26% of patients in the 1955–74 cohort, 40% in the 1975–84 cohort, and 70% in the 1985–94 cohort had received a DMARD (log-rank p < 0.001). Age, rheumatoid factor (RF) positivity, erythrocyte sedimentation rate, large joint swelling, rheumatoid nodules, and destructive changes on radiographs were significantly associated with time to first DMARD regimen after adjustment for calendar time and sex. Patients who were older and RF positive and who did not receive CS were more likely to have received more DMARD regimens. Conclusion. Time to initiation of DMARD therapy has shortened markedly over the past 3–4 decades. These changes in management of early RA provide evidence for the translation of scientific evidence into clinical practice in rheumatology. Age and various disease characteristics are significantly associated with initiation and the number of DMARD regimens used. These should be considered as confounders when examining the effect of early DMARD treatment on disease progression and mortality. (J Rheumatol 2004;31:2366-;73) Key Indexing Terms:
RHEUMATOID ARTHRITIS
From the Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA. Supported in part by grants from the National Institutes of Health, NIAMS (R01 R46849), the National Institutes of Health (AR-30582) US Public Health Service, and the Arthritis Foundation North Central Chapter. Dr. Nicola is supported in part by a Fellowship from the Luso-American Foundation. H.M. Kremers, MD, MSc; P. Nicola, MD; C.S. Crowson, BS; W.M. O'Fallon, PhD; S.E. Gabriel, MD, MSc. Address reprint requests to Dr. S.E. Gabriel, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: gabriel.sherine@mayo.edu Submitted February 16, 2004; revision accepted June 28, 2004. |