Changes in the pharmacological management of rheumatoid arthritis over two decades

Abstract

Objectives To assess whether modern management of rheumatoid arthritis (RA) has reduced the prescription of oral corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) and to evaluate use of pharmacological prophylaxis strategies. Methods Using the Clinical Practice Research Datalink, we explored long-term (≥3/12 months; ≥6/12 in sub-analyses) disease modifying antirheumatic drug (DMARD), corticosteroid and NSAID prescribing (annually, in the year post-diagnosis and across the patient’s life-course to 15 years post-diagnosis), annual proportion with co-prescribing for prophylaxis of associated bone (corticosteroids, women only) and gastrointestinal (NSAIDs) comorbidity. Results Reported incidence of RA was 5.98 (±0.37) per 10 000 person-years and prevalence was 0.91% (±0.014) in 2017. In 71 411 RA patients, long-term DMARD prescribing initially rose post-diagnosis from 41.6% in 1998–67.9% in 2009. Corticosteroid prescribing changed little, overall (22.2% in 1998, 19.1% in 2016; incident risk ratio (IRR) 0.92, 95% CI 0.82–1.03) and across the life-course from the first to fifteenth year (22.2% to 16.9%). NSAID prescribing declined from 57.7% in 1998, and significantly so from 2008, to 27.1% in 2016 (IRR 0.50, 95% CI 0.44–0.56). This continued across the life-course (41.2% to 28.4%). Bone prophylaxis increased to 68.1% in 2008 before declining to 56.4% in 2017; gastrointestinal prophylaxis increased from 11.5% in 1998–62.6% in 2017. Sub-analyses showed consistent patterns. Conclusion Despite modern treatment strategies, corticosteroid prescribing in RA patients remains substantial and persists beyond 6 months once initiated. Rheumatologists need to determine causes and develop strategies to reduce corticosteroid use to minimise adverse event occurrence.

'Difficult to treat' rheumatoid arthritis: current position and considerations for next steps

“… 22 Incorporating intermittent use of oral and/or intramuscular glucocorticoid in the assessment is challenging, and our still liberal use is likely to be masking the true extent of refractory RA. 23 …”

“…The cut-off in glucocorticoid dose greater than 7.5 mg daily as a reflection of ineffective b/tsDMARD is debatable, and doses of 7.5 mg daily and lower risk being an ongoing contributor to comorbidities and/or D2T trajectory 22. Incorporating intermittent use of oral and/or intramuscular glucocorticoid in the assessment is challenging, and our still liberal use is likely to be masking the true extent of refractory RA 23…”

Real-world effectiveness and persistence of reference etanercept versus biosimilar etanercept GP2015 among rheumatoid arthritis patients: A cohort study

“…A significantly higher proportion of patients with erosive disease and in treatment with corticosteroids therapy at baseline were also observed in the ETN group. Bone erosions are generally associated with disease severity and consistent with advanced disease ( Fuchs et al, 1989 ) and these findings could be justified by the update in RA treatment strategies, which lately employ early initiation of DMARDs and concomitant short-term corticosteroids to suppress inflammation, especially in early RA ( Crossfield et al, 2021 ; Smolen et al, 2020 ).…”

Adipose-Derived Stem Cell Exosomes as a Novel Anti-Inflammatory Agent and the Current Therapeutic Targets for Rheumatoid Arthritis

“…The currently available therapeutic drugs used for RA treatment can be classified into nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, nonbiologic or conventional synthetic DMARDs (csDMARDs), biologic agents or bDMARDs, and targeted synthetic DMARDs (tsDMARDs) [ 28 ]. NSAIDs are most frequently used to mitigate pain.…”