title: Changing clinical patterns in rheumatoid arthritis management over two decades: sequential observational studies.
abstract: BACKGROUND
  Rheumatoid arthritis (RA) treatment paradigms have shifted over the last two decades. There has been increasing emphasis on combination disease modifying anti-rheumatic drug (DMARD) therapy, newer biologic therapies have become available and there is a greater focus on achieving remission. We have evaluated the impact of treatment changes on disease activity scores for 28 joints (DAS28) and disability measured by the health assessment questionnaire scores (HAQ).
  
  
  METHODS
  Four cross-sectional surveys between 1996 and 2014 in two adjacent secondary care rheumatology departments in London evaluated changes in drug therapy, DAS28 and its component parts and HAQ scores (in three surveys). Descriptive statistics used means and standard deviations (SD) or medians and interquartile ranges (IQR) to summarise changes. Spearman's correlations assessed relationships between assessments.
  
  
  RESULTS
  1324 patients were studied. Gender ratios, age and mean disease duration were similar across all cohorts. There were temporal increases in the use of any DMARDs (rising from 61% to 87% of patients from 1996-2014), combination DMARDs (1% to 41%) and biologic (0 to 32%). Mean DAS28 fell (5.2 to 3.7), active disease (DAS28 > 5.1) declined (50% to 18%) and DAS28 remission (DAS28 < 2.6) increased (8% to 28%). In contrast HAQ scores were unchanged (1.30 to 1.32) and correlations between DAS28 and HAQ weakened (Spearman's rho fell from 0.56 to 0.44).
  
  
  CONCLUSIONS
  Treatment intensity has increased over time, disease activity has fallen and there are more remissions. However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. As a consequence the relationship between DAS28 and HAQ has become weaker over time. Although the reasons for this divergence between disease activity and disability are uncertain, focussing treatment entirely in suppressing synovitis may be insufficient.
authors.affiliation: Department of Rheumatology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. aneela.mian@nhs.net.|Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. aneela.mian@nhs.net.
authors.forename: Aneela N
authors.initials: AN
authors.lastname: Mian
authors.affiliation: Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. Fowzia.ibrahim@kcl.ac.uk.
authors.forename: Fowzia
authors.initials: F
authors.lastname: Ibrahim
authors.affiliation: Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. Ian.scott@gstt.nhs.uk.
authors.forename: Ian C
authors.initials: IC
authors.lastname: Scott
authors.affiliation: Department of Rheumatology, University Hospital Lewisham, London, SE13 6LH, UK. Sardar.bahadur@nhs.net.
authors.forename: Sardar
authors.initials: S
authors.lastname: Bahadur
authors.affiliation: Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. Maria.filkova@kcl.ac.uk.
authors.forename: Maria
authors.initials: M
authors.lastname: Filkova
authors.affiliation: Department of Rheumatology, University Hospital Lewisham, London, SE13 6LH, UK. louisepollard@nhs.net.
authors.forename: Louise
authors.initials: L
authors.lastname: Pollard
authors.affiliation: Department of Rheumatology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. Sophia.steer@nhs.net.|Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. Sophia.steer@nhs.net.
authors.forename: Sophia
authors.initials: S
authors.lastname: Steer
authors.affiliation: Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. Gabrielle.kingsley@nhs.net.|Department of Rheumatology, University Hospital Lewisham, London, SE13 6LH, UK. Gabrielle.kingsley@nhs.net.
authors.forename: Gabrielle H
authors.initials: GH
authors.lastname: Kingsley
authors.affiliation: Department of Rheumatology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. d.scott1@nhs.net.|Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. d.scott1@nhs.net.
authors.forename: David L
authors.initials: DL
authors.lastname: Scott
authors.affiliation: Department of Rheumatology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. james.galloway@kcl.ac.uk.|Department of Rheumatology, King's College School of Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK. james.galloway@kcl.ac.uk.
authors.forename: James
authors.initials: J
authors.lastname: Galloway
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors
chemical_list: D018501:Antirheumatic Agents
references.citation: Arthritis Rheum. 2001 Sep;44(9):2009-17
references.pmid: 11592361
references.citation: Best Pract Res Clin Rheumatol. 2001 Mar;15(1):67-76
references.pmid: 11358415
references.citation: Ann Rheum Dis. 2015 Feb;74(2):381-8
references.pmid: 24285493
references.citation: J Rheumatol. 2004 Jun;31(6):1073-82
references.pmid: 15170917
references.citation: J Chronic Dis. 1983;36(12):891-7
references.pmid: 6655034
references.citation: Br J Rheumatol. 1997 Jan;36(1):69-73
references.pmid: 9117179
references.citation: Arthritis Rheum. 2005 Apr;52(4):1009-19
references.pmid: 15818706
references.citation: Arthritis Rheum. 2005 Sep;52(9):2616-24
references.pmid: 16142762
references.citation: Ann Rheum Dis. 2006 Sep;65(9):1192-7
references.pmid: 16540549
references.citation: J Gerontol B Psychol Sci Soc Sci. 2007 Jan;62(1):S11-21
references.pmid: 17284560
references.citation: Rheumatology (Oxford). 2007 Aug;46(8):1345-54
references.pmid: 17562686
references.citation: Ann Rheum Dis. 2007 Nov;66(11):1534-7
references.pmid: 17660223
references.citation: Health Qual Life Outcomes. 2003;1:20
references.pmid: 12831398
references.citation: J Rheumatol. 2009 Aug;36(8):1596-9
references.pmid: 19531746
references.citation: Ann Rheum Dis. 2010 Apr;69(4):629-30
references.pmid: 20237122
references.citation: Lancet. 2010 Sep 25;376(9746):1094-108
references.pmid: 20870100
references.citation: Clin Exp Rheumatol. 2012 Mar-Apr;30(2):228-32
references.pmid: 22325679
references.citation: Rheumatology (Oxford). 2013 Aug;52(8):1500-8
references.pmid: 23657913
references.citation: Rheumatology (Oxford). 2013 Dec;52(12):2136-48
references.pmid: 24003249
references.citation: Arthritis Rheumatol. 2014 May;66(5):1081-9
references.pmid: 24782174
references.citation: J Rheumatol. 2014 Aug;41(8):1590-9
references.pmid: 24986850