The number of hospital admissions and joint replacements among rheumatoid arthritis patients in Ireland dropped dramatically between 1995 and 2010, according to a study presented at the 2012 annual meeting of the American College of Rheumatology.

The researchers link wide use of TNF inhibitors with these positive outcomes – specifically, a 13 percent yearly reduction in hospital stays and a 10 percent yearly reduction in the number of musculoskeletal surgeries. The study looked at nearly 58,000 hospital records of rheumatoid arthritis, or RA, patients throughout Ireland.

“The strength of this study is that this data is national, including all 57 public hospitals,” says study co-author Oliver FitzGerald, MD, consultant rheumatologist at St. Vincent’s University Hospital in Dublin. The weak spot of the study, he says, is that RA may have been miscoded as osteoarthritis, or OA, in some cases – and private hospitals were not included.

This research builds on a body of evidence linking the use of powerful RA drugs with improved patient outcomes. One study published earlier this year in The Journal of Rheumatology found that people diagnosed with RA in the past 15 years are less likely to need joint surgery than those diagnosed previously. Researchers behind that study, from the Mayo Clinic in Rochester, Minn., attribute this to aggressive treatment of RA with traditional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, as well as biologics, which were introduced in the U.S. in the late 1990s.

“The general consensus is that RA patients are doing so much better in the last decade than before. This large, national register-based study [in Ireland] provides credible data to support this,” says Arnold Ceponis, MD, PhD, a rheumatologist with the University of California, San Diego, Health System.
 

Dr. Ceponis says it’s likely the TNF inhibitors are keeping patients out of the hospital in part because of their positive effect on the cardiovascular system. “Any chronic inflammation, including RA, is associated with damage to blood vessels in the long term,” Dr. Ceponis says. “Recently studies have started popping up that not only methotrexate, but also TNF inhibitors can reverse increased risk of cardiovascular disease in RA patients. Since RA is a systemic disease, the mechanism of this has likely to do with overall reduction of the chronic inflammatory burden – which in the long term translates into better cardiovascular health.” 

The study raises the question of whether more RA patients should be treated with TNF inhibitors.

“Introduction of TNF inhibitors was the biggest breakthrough in the RA field since widespread introduction of methotrexate,” Dr. Ceponis says. “We now have an additional, powerful tool for the management of RA. But does that mean everybody needs this tool? No.”

Dr. Ceponis says that for most of his patients, traditional DMARDs such as methotrexate will remain first-line therapy. “Three to six months down the line we usually get a good idea whether this will be sufficient,” he says. “If not, we add a TNF inhibitor.”

The authors of the Irish study acknowledge that factors other than TNF inhibitor usage, including use of traditional DMARDs and better management of complications, may have contributed to “improved patient outcomes.”

But Dr. Ceponis says that despite some flaws, the study highlights an important pharmaceutical advancement. “Without overestimation, most rheumatologists believe that TNF inhibitors have made a revolution in what we do in the field,” he says. “With proper use, we can probably change the natural history and progression of the disease not only in the joints, but also in the whole body. The results of this study lend some support for that.”