Impact of physicians' adherence to treat-to-target strategy on outcomes in early rheumatoid arthritis in the NEO-RACo trial.
OBJECTIVE
It is well recognized that medication adherence of rheumatoid arthritis (RA) patients is often poor. As less attention has been paid to physicians' adherence to targeted treatment, we aimed to investigate how it affects outcomes in aggressively treated early RA patients.


METHODS
In the new Finnish RA Combination Therapy (NEO-RACo) trial, 99 patients with early active RA were treated, targeting remission, with a combination of methotrexate, sulfasalazine, hydroxychloroquine, and low-dose prednisolone for 2 years, and randomized to receive infliximab or placebo for the initial 6 months. After 2 years, therapy was unrestricted while remission was still targeted. Patients were divided into tertiles by physicians' adherence to treat-to-target, which was evaluated with a scoring system during the initial 2 years. After 5 years of follow-up, the between-tertile differences in remission rates, 28-joint Disease Activity Score (DAS28) levels, radiological changes, cumulative days off work, and the use of anti-rheumatic medication were assessed.


RESULTS
Follow-up data were available for 93 patients. Physicians' good adherence was associated with improved remission rates at 2-4 years and lower DAS28 levels throughout the follow-up. In a multivariable model, physicians' adherence was the most important predictor of remission at 3 months and 2 years (p < 0.001 for both). Between 2 and 5 years, biologics were used more often in the tertile of low adherence compared with the other two groups (p = 0.024). No significant differences were observed in radiological progression and cumulative days off work.


CONCLUSIONS
Physicians' good adherence is associated with improved remission rates and lesser use of biologics in early RA.
a Department of Internal Medicine, Division of Rheumatology , Turku University Hospital , Finland.
L
L
Kuusalo
b South-Karelia Central Hospital , Lappeenranta , Finland.
K
K
Puolakka
c Unit of Primary Health Care , Helsinki University Hospital , Finland.|d Department of General Practice , University of Helsinki , Finland.
H
H
Kautiainen
e Seinäjoki Central Hospital , Finland.
H
H
Blåfield
f Rheumatology , University of Helsinki , Finland.|g Rheumatology , Helsinki University Hospital , Finland.
K K
KK
Eklund
h Hämeenlinna Central Hospital , Finland.
K
K
Ilva
i Department of Medicine , Kuopio University Hospital , Finland.
O
O
Kaipiainen-Seppänen
j Department of Medicine , Oulu University Hospital , Finland.
A
A
Karjalainen
k Department of Internal Medicine , Centre for Rheumatic Diseases, Tampere University Hospital , Finland.
M
M
Korpela
g Rheumatology , Helsinki University Hospital , Finland.
H
H
Valleala
f Rheumatology , University of Helsinki , Finland.|g Rheumatology , Helsinki University Hospital , Finland.
M
M
Leirisalo-Repo
k Department of Internal Medicine , Centre for Rheumatic Diseases, Tampere University Hospital , Finland.
V
V
Rantalaiho
D000328:Adult; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000453:epidemiology*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D005387:Finland; D005500:Follow-Up Studies; D006801:Humans; D006886:Hydroxychloroquine / Q000008:administration & dosage / Q000627:therapeutic use; D000069285:Infliximab / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage / Q000627:therapeutic use; D008875:Middle Aged; D015999:Multivariate Analysis; D010818:Practice Patterns, Physicians'; D011239:Prednisolone / Q000008:administration & dosage / Q000627:therapeutic use; D012074:Remission Induction; D012460:Sulfasalazine / Q000008:administration & dosage / Q000627:therapeutic use; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D012460:Sulfasalazine; D006886:Hydroxychloroquine; D011239:Prednisolone; D000069285:Infliximab; D008727:Methotrexate