Influencers of deterioration in patients with Rheumatoid Arthritis on DMARD therapy

Abstract

Objective: To identify the sociodemographic, clinical and health care factors that influence deterioration to Disease Modifying Antirheumatic Drugs (DMARDS) in patients with Rheumatoid Arthritis (RA).

Methods: We conducted a prospective cohort study on RA patients diagnosed according to the ACR (1987) or ACR/ EULAR criteria (2010). These patients were followed up in four rheumatology clinics in three counties in Kenya. A pre-coded questionnaire was used to capture socio-demographic and clinical characteristics of the patients. Baseline data was collected at the time of recruitment into the study. Patients were then followed up while on treatment with DMARDS and only those who had complete data at 3 months were included in the study analysis. The study outcome was defined using Disease Activity Score 28 (DAS-28) as either remission or Low Disease Activity (LDA) at 3 months follow-up. The Adherence in Chronic Disease Scale (ACDS) was used to assess the implementation of the treatment plan. Data analysis was carried out using Prism7 and SPSS version 25, p value of < 0.05 was considered statistically significant.

Results: Of the 206 patients included, the mean age was 51.2 ± 15.1 years with female predominance (91.3%). Majority (83.5%) had post primary education, only 35.9% had formal professional employment and 3% had medical insurance. At recruitment, nearly half of the included patients (47.6%) had an overall health assessment questionnaire disability index (HAQ-DI) score of > 2.5, indicating moderate to severe disability. The majority of patients had elevated baseline Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP). Most (90.3%) of the patients had a positive Rheumatoid Factor (RF) test at recruitment, and 58.5% of patient had a positive anti-Cyclic Citrullinated Peptide (Anti-CCP) test. Twelve percent, 62%, 10% and 16% of the patients had High Disease Activity (HDA), Moderate Disease Activity (MDA), Low Disease Activity (LDA) and remission respectively. Majority (94.2%) of patients were on Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), 80.6% were on Conventional Disease Modifying AntiRheumatic Drugs (CsDMARDs) and 55% on systemic corticosteroids. The mean duration of follow-up was 4.6 months. During the follow-up, 37.9% found the system to be acceptable and 63.6% found the system to be problematic. Majority of the patients reported to have been adherent to therapy (7.8% were high adherence: 87% were moderate adherence). A total of 52 (27.7%) patients deteriorated (had severe disease activity at follow up). A high baseline of DAS-28 score (OR = 4.4, 95% CI 2.67-7.57, P<0.001) and nonadherence (OR=30.4, 95% CI 4.82-191.66, p<0.001) were identified as independent predictors of deterioration.

Conclusion: High baseline of DAS-28 and non-adherence are independent predictors of disease deterioration in patients with RA.