title: Management of rheumatoid arthritis in clinical practice using treat-to-target strategy: Where do we stand in the multi-ethnic Malaysia population?
abstract: To evaluate the achievement of treat-to-target (T2T) strategy in rheumatoid arthritis (RA) and identify factors associated with failed treatment target in a public rheumatology center. A cross-sectional study was conducted from June 2015 to February 2016. RA patients with disease duration greater than 2 years and under T2T for over a year were invited to the study. Demographic, clinical data, disease activity score of 28 joints (DAS28), and clinical disease activity index (CDAI) were collected in a single routine clinic visit. Treatment target was defined as DAS28 <3.2 or CDAI ≤10. Retrospective chart review was performed to determine reasons of failed treatment target. A total of 371 patients were recruited and 87.1% were female. Mean age and duration of RA were 53.5 years (SD 10.3) and 9.1 years (SD 6.6), respectively. Ethnic distribution was 49% Chinese, 27% Malay, and 24% Indian. T2T was achieved in 81.7% of the cohort. Non-Chinese ethnicity, positive rheumatoid factor, and treatment with three disease modifying anti-rheumatic drugs (DMARDs) were associated with failed treatment target. After controlling for covariates, Malay ethnicity (OR 2.96; 95% CI 1.47-5.96) and treatment with three DMARDs (OR 2.14; 95% CI 1.06-4.35) were associated with failed treatment target. There was no association between age, gender, duration of RA, BMI, smoking status, anti-citrulinated cyclic peptide, and achievement of T2T. The most common reasons of failed treatment target were inability to escalate DMARDs due to side effects (18.8%), lack of biologics fund (15.6%), and persistent disease despite optimum treatment (14.1%). T2T was successfully implemented. Malay patients need aggressive treatment adaptation to achieve optimal outcome.
authors.affiliation: Rheumatology Unit, Department of Medicine, Hospital Pulau Pinang, Jalan Residensi, 10990, Penang, Malaysia. tbeeng3@yahoo.com.
authors.forename: Bee Eng
authors.initials: BE
authors.lastname: Tan
authors.affiliation: Rheumatology Unit, Department of Medicine, Hospital Pulau Pinang, Jalan Residensi, 10990, Penang, Malaysia.
authors.forename: Ai Lee
authors.initials: AL
authors.lastname: Lim
authors.affiliation: Rheumatology Unit, Department of Medicine, Hospital Pulau Pinang, Jalan Residensi, 10990, Penang, Malaysia.
authors.forename: Sow Lai
authors.initials: SL
authors.lastname: Kan
authors.affiliation: Rheumatology Unit, Department of Medicine, Hospital Pulau Pinang, Jalan Residensi, 10990, Penang, Malaysia.
authors.forename: Chong Hong
authors.initials: CH
authors.lastname: Lim
authors.affiliation: Rheumatology Unit, Department of Medicine, Hospital Pulau Pinang, Jalan Residensi, 10990, Penang, Malaysia.
authors.forename: Ying Fun
authors.initials: YF
authors.lastname: Ng
authors.affiliation: Clinical Research Center, Hospital Pulau Pinang, Penang, Malaysia.
authors.forename: Serene Li Ching
authors.initials: SLC
authors.lastname: Tng
authors.affiliation: Clinical Research Center, Hospital Pulau Pinang, Penang, Malaysia.
authors.forename: Nur Syakirah
authors.initials: NS
authors.lastname: Hassin
authors.affiliation: Clinical Research Center, Hospital Pulau Pinang, Penang, Malaysia.
authors.forename: Losshenee
authors.initials: L
authors.lastname: Chandran
authors.affiliation: Clinical Research Center, Hospital Pulau Pinang, Penang, Malaysia.
authors.forename: Norshahida Abdul
authors.initials: NA
authors.lastname: Hamid
authors.affiliation: Outcome and Evidence, Health and Value, Pfizer Malaysia Sdn Bhd, Kuala Lumpur, Malaysia.
authors.forename: Yvonne Yin Leng
authors.initials: YYL
authors.lastname: Lee
mesh_terms: D000328:Adult; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000600:supply & distribution / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology; D001688:Biological Products / Q000600:supply & distribution / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D000071066:Patient Reported Outcome Measures; D010818:Practice Patterns, Physicians'; D012074:Remission Induction; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D017211:Treatment Failure
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products
keywords: Clinical; Outcome; Rheumatoid arthritis; Routine; Treat-to-target