The impact of intensive treatment and remission on health-related quality of life in rheumatoid arthritis

Abstract

BackgroundThe current model of rheumatoid arthritis management is treat to target, which involves intensive treatment that is titrated until remission from disease activity is attained. Another treatment target that might be more important to patients is normalising health-related quality of life (HRQoL). HRQoL is a multidimensional concept; whether remission and intensive treatment improve all dimensions equally is uncertain. We evaluated the impact of intensive treatment and remission on HRQoL in rheumatoid arthritis. MethodsPatients enrolled to the CARDERA and TACIT trials were evaluated. CARDERA randomised 467 patients to 6 months of either active or placebo high-dose corticosteroids; TACIT randomised 205 patients to 1 year of combination disease-modifying antirheumatic drugs (DMARDs) or tumour necrosis factor α inhibitors (TNFi). We measured HRQoL with the Short Form 36 (SF-36), capturing information on physical and mental health across eight domains. The effect of treatment and remission on SF-36 scores was evaluated by linear regression and spydergrams, respectively. FindingsCorticosteroids resulted in significant improvements in physical health, relative to placebo (physical component summary [PCS] score β=3·78, p=0·0001); no effects were seen on mental health (as judged by mental component summary [MCS] score). TNFi therapy provided a greater improvement in physical health than did combination DMARDs (PCS β=3·04, p=0·034); no difference in mental health improvement was observed. In both trials, patients in remission at the final timepoint had physical health scores substantially below those seen in the normal UK population. Normalised PCS and MCS scores (which have a mean score of 50 in the general population) for patients in remission were, respectively, 46 (SD 9·3) and 52 (11·5) in CARDERA and 40 (10·5) and 53 (9·8) in TACIT. InterpretationWe found that intensive rheumatoid arthritis treatment does not improve all aspects of HRQoL: corticosteroids and TNFi provided improvements in physical but not mental health, relative to placebo and combination DMARDs, respectively. Although remission improved HRQoL, it did not normalise physical health. Therefore, measures specifically targeting HRQoL are needed. The study's strength is its replication of key findings across two trials; that it did not test a prespecified hypothesis is a key limitation. FundingNational Institute for Health Research.