When it comes to reducing the number of sick days among patients with early rheumatoid arthritis (RA), taking traditional disease-modifying antirheumatic drugs (DMARDs) works as well as taking a biologic drug, according to a new analysis published online earlier this month in JAMA Internal Medicine.
Patients on a biologic have slightly better outcomes than those taking traditional DMARDs, but researchers in Sweden found that those outcomes did not translate to fewer sick days.
Using data from the Swedish Pharmacotherapy study, researchers looked at the 204 early RA patients (with symptom duration of less than a year) who hadn’t responded adequately to three months of methotrexate. Of those, 105 were randomly assigned to receive the biologic drug infliximab (Remicade) along with methotrexate, and 99 received “triple therapy” of sulfasalazine (Azulfidine) and hydroxychloroquine (Plaquenil) along with methotrexate. Researchers then compared the numbers of sick leave days and disability pension days patients used over almost two years.
“Work loss is the largest driver of costs associated with rheumatoid arthritis and is highly prevalent already among patients with newly diagnosed rheumatoid arthritis,” explains lead study author Jonas K. Eriksson, a doctoral student in the department of medicine at Karolinska Institute in Stockholm. “Therefore, we think that work loss in rheumatoid arthritis is an important outcome when comparing different treatment strategies.”
Patients in both groups had the same average number of sick days at the start of the study – 17 days per month, which is three times the number taken in the general population. By the end of the 21 months, sick days among patients in the biologic group decreased by 4.9 days per month to 12, while the triple therapy group’s decreased by 6.2 days a month to 10 – numbers that, although better, are still double those in the general population.
Researchers say this shows that early and aggressive treatment in methotrexate-resistant patients not only stops the trend of increasing sick days, but also partly reverses it.
This decrease in sick days clearly benefits the individual. “From an individual perspective, work loss is often important for patients, and being unable to work affects personal finances and self-esteem,” says Eriksson.
But it also benefits society – especially for countries like Sweden that have tax-funded health care – but as well as for countries like the United States, where many have private insurance. “Health care resources are of course not infinite, and to allocate the available resources in the best possible way should be the goal,” Eriksson says. “Since the introduction of [biologics] there has been a growing interest in economic evaluations in rheumatoid arthritis and to assess whether the increased drug costs will be offset by reduced productivity losses. The drug cost for one year of biological treatment is around 10 times higher than the drug cost of conventional combination treatment.”
Edward H. Yelin, PhD, a professor of medicine and health policy in the division of occupational and environmental health at the University of California, San Francisco wrote an editorial accompanying the study, also published in JAMA Internal Medicine. He says this is a well-done trial with an important finding for patients, because earlier studies show that without aggressive treatment, 10 percent of RA patients stop working within a year of diagnosis and 50 percent do so within 10 years.
“In some ways it matters less what we do than that we use treatments aggressively when we have the opportunity to do that,” Yelin explains. “If you treat patients aggressively [early on], not only will they get symptom relief, but they may also work more than they would have otherwise or keep their jobs.”
Even so, Yelin says it’s important to realize this study did not replicate the real-world scenario where insurance companies typically won’t cover the use of more expensive biologic medications until someone has failed one or even two traditional nonbiologic DMARDs. He says that means a patient’s disease activity may have progressed further by the time they take a biologic, which could adversely affect their ability to work even more.
“But these trial results still indicate there is much that can be done. It may not be quite what they achieved in the trial, but it’s still there for the taking,” Yelin says.
He would like to see future research assess whether there is a difference in work loss among RA patients with established disease, who have already progressed passed initial, unsuccessful treatments.
This study was funded by the Swedish Rheumatism Association and the pharmaceutical company Schering-Plough/Merck Sharp and Dohme; the researchers say the drug company had no part in the study design or data assessment.