Incident Rheumatoid Arthritis Patients Research Articles

A Narrowing Mortality Gap: Temporal Trends of Cause-Specific Mortality in a National Matched Cohort Study in US Veterans With Rheumatoid Arthritis.

To examine temporal trends in all-cause and cause-specific mortality in patients with rheumatoid arthritis (RA) in the Veterans Health Administration (VHA). We conducted a matched cohort study in the VHA from January 1, 2000 to December 31, 2017. Incident RA patients were matched up to 1:10 on age, sex, and VHA enrollment year to non-RA patients, then followed until death or end of study period. Cause of death was obtained from the National Death Index. Multivariable Cox regression models stratified by RA diagnosis years were used to examine trends in RA-related risk of all-cause and cause-specific mortality. Among 29,779 incident RA patients (matched to 245,226 non-RA patients), 9,565 deaths occurred. RA patients were at increased risk of all-cause (adjusted hazard ratio [HRadj ] 1.23 [95% confidence interval (95% CI) 1.20-1.26]), cardiovascular (HRadj 1.19 [95% CI 1.14-1.23]), cancer (HRadj 1.19 [95% CI 1.14-1.24]), respiratory (HRadj 1.46 [95% CI 1.38-1.55]), and infection-related mortality (HRadj 1.59 [95% CI 1.41-1.80]). Interstitial lung disease was the cause of death most strongly associated with RA (HRadj 3.39 [95% CI 2.88-3.99]). Nearly 70% of excess deaths in RA were attributable to cardiopulmonary disease. All-cause mortality risk related to RA was lower among those diagnosed during 2012-2017 (HRadj 1.10 [95% CI 1.05-1.15]) compared to 2000-2005 (HRadj 1.31 [95% CI 1.26-1.36]), but still higher than for non-RA controls (P < 0.001). Cause-specific mortality trends were similar. Excess RA-related mortality was driven by cardiovascular, cancer, respiratory, and infectious causes, particularly cardiopulmonary diseases. Although our findings support that RA-related mortality risk is decreasing over time, a mortality gap remains for all-cause and cause-specific mortality in RA.

System-level performance measures of access to rheumatology care: a population-based retrospective study of trends over time and the impact of regional rheumatologist supply in Ontario, Canada, 2002–2019

ObjectiveTo determine whether there were improvements in rheumatology care for rheumatoid arthritis (RA) between 2002 and 2019 in Ontario, Canada, and to evaluate the impact of rheumatologist regional supply on access.MethodsWe conducted a population-based retrospective study of all individuals diagnosed with RA between January 1, 2002 and December 31, 2019. Performance measures evaluated were: (i) percentage of RA patients seen by a rheumatologist within one year of diagnosis; and (ii) percentage of individuals with RA aged 66 years and older (whose prescription drugs are publicly funded) dispensed a disease modifying anti-rheumatic drug (DMARD) within 30 days after initial rheumatologist visit. Logistic regression was used to assess whether performance improved over time and whether the improvements differed by rheumatology supply, dichotomized as < 1 rheumatologist per 75,000 adults versus ≥1 per 75,000.ResultsAmong 112,494 incident RA patients, 84% saw a rheumatologist within one year: The percentage increased over time (adjusted odds ratio (OR) 2019 vs. 2002 = 1.43, p < 0.0001) and was consistently higher in regions with higher rheumatologist supply (OR = 1.73, 95% CI 1.67–1.80). Among seniors who were seen by a rheumatologist within 1 year of their diagnosis the likelihood of timely DMARD treatment was lower among individuals residing in regions with higher rheumatologist supply (OR = 0.90 95% CI 0.83–0.97). These trends persisted after adjusting for other covariates.ConclusionWhile access to rheumatologists and treatment improved over time, shortcomings remain, particularly for DMARD use. Patients residing in regions with higher rheumatology supply were more likely to access care but less likely to receive timely treatment.

Impact of continuity of care on risk for major osteoporotic fracture in patients with new onset rheumatoid arthritis

There is a clear relationship between rheumatoid arthritis (RA) and major osteoporotic fracture (MOF), although there is limited evidence on the effect of continuity of care (COC) on MOF in these patients. We investigated the association between COC and risk of MOF, including fractures of the lumbar spine and pelvis, forearm, and hip, among newly diagnosed RA patients aged ≥ 60 years. A total of 8715 incident RA patients from 2004 to 2010 were included from the Korean National Health Insurance Service-Senior cohort database. Participants were categorized into a good and bad COC group according to the COC index. The cumulative incidence of MOF was higher in RA patients with bad than in those with good COC (p < 0.001). The incidence rates of MOF were 4439 and 3275 cases per 100,000 person-years in patients with bad and good COC, respectively. RA patients with bad COC had an increased incidence of overall MOF (adjusted hazard ratio, 1.32; 95% confidence interval, 1.14–1.53), with the highest increase in risk being that of forearm fracture. An increased MOF risk in patients with bad COC was predominantly observed in females. This study suggested that interventions that can improve COC in patients with RA should be considered.

Risk of Staphylococcus aureus bacteraemia in patients with rheumatoid arthritis and the effect of orthopaedic implants on the risk: a nationwide observational cohort study

Objective It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants. Method Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996–2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status. Results The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6–12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18–59-year-old RA patients were 2.6 (95% confidence interval 1.8–3.7) for women and 1.8 (1.1–3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3–2.8) (women ≥ 70 years) to 5.3 (2.2–12.8) (18–59-year-old men). Conclusion In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants.

A Comparison of the Risk of Fracture in Rheumatoid Arthritis Patients with and without Receiving Chinese Herbal Medicine.

ObjectivePatients with rheumatoid arthritis (RA) often suffer from bone complications due to persistent joint inflammation, especially incident fracture. Nowadays, Chinese herbal medicines (CHMs) have provided safe and effective therapy for treating skeletal conditions, but it is unclear whether CHMs can prevent fracture onset among RA individuals. This study aimed to determine the association between the use of CHMs and the risk of fracture among them.MethodsThis retrospective, population-based study retrieved administrative health data from the Taiwan National Health Insurance (NHI) database to identify patients with newly diagnosed RA between 2000 and 2009. Of the 6178 incident RA patients, 2495 matched pairs of CHMs users and non-CHMs users were identified by propensity score matching. Enrollees with hip fractures prior to RA onset were excluded. Included subjects were followed until the end of 2013. Incidence and adjusted hazard ratios (HR) of new-onset bone fracture in the multivariable Cox proportional hazard model were measured with 95% confidence interval (CI).ResultsFracture incidence was lower in CHMs users than in the comparison cohort (26.91 vs 32.94 per 1000 person-years, respectively), with an adjusted HR of 0.82 (95% CI: 0.73–0.92). Subjects receiving CHMs for more than 2 years had a much lower risk of fracture onset by more than 50%. Some CHMs prescriptions (Yan Hu Suo, Bei Mu, Da Huang, Dang Shen, Fu-Zi, Shu-Jing-Huo-Xue-Tang, Dang-Gui-Nian-Tong-Tang, Jia-Wei-Xiao-Yao-San, Gan-Lu-Yin, and Gui-Zhi-Shao-Yao-Zhi-Mu-Tang) were associated with reduced fracture risk.ConclusionAdding CHMs to routine treatment was found to be related to lower fracture risk in RA patients.

Risk of New-Onset Acute Coronary Syndrome and Atrial Fibrillation in Patients With Rheumatoid Arthritis Compared With a Risk-Set and Propensity Score-Matched Cohort - A Nationwide Cohort Study.

Rheumatoid arthritis (RA) has extra-articular manifestations of cardiovascular diseases and is associated with a high mortality rate in Western populations. This study aimed to investigate the risk of acute coronary syndrome (ACS) and atrial fibrillation (AF) associated with RA in a Korean population. Patients were selected from a senior cohort from the Korean National Health Insurance Service in 2002, and followed until 31 December 2015. Patients with newly developed ACS and AF were identified and compared with controls for a 10-year period using time-dependent propensity and risk-set matching. A total of 4,217 incident RA patients and their 8,432 controls comprised the incident RA and matched cohorts, respectively. ACS was identified during 24,642 person-years [incidence rate (IR) 402 per 10,000 person-years, 95% confidence interval (CI) 330-489] among the RA cohort. In the matched cohort, 141 ACS patients were identified during 50,011 person-years (IR 282 per 100,000 person-years, 95% CI 239-333). RA patients were 1.43-fold more likely to develop ACS than the matched controls [hazard ratio (HR) 1.43, 95% CI 1.10-1.84], but showed similar occurrence risk of AF (HR 1.06, 95% CI 0.83-1.35). A higher risk for ACS and a similar risk for AF were found by risk-set matched analysis in a senior RA cohort compared with the control, using Korean nationwide long-term data.

Factors associated with risk of major adverse cardiovascular events in patients with rheumatoid arthritis: a nationwide, population-based, case-control study

Objectives:To investigate factors associated with major adverse cardiovascular events (MACEs) in patients with rheumatoid arthritis (RA).Methods:We conducted a nationwide, population-based, case-control study using Taiwan’s National Health Insurance Research Database for 2003–2013. From 2004 to 2012, we identified 108,319 newly diagnosed RA patients without previous MACEs, of whom 7,580 patients (7.0%) developed MACEs during follow-up. From these incident RA patients, we included 5,994 MACE cases and 1:4 matched 23,976 non-MACE controls for analysis. The associations of MACEs with comorbidities and use of anti-rheumatic medications within 1 year before the index date were examined using conditional logistic regression analyses.Results:Using multivariable conditional logistic regression analysis, the risk of MACE in RA patients was associated with use of golimumab [odd’s ratio (OR), 0.09; 95% confidence interval (CI), 0.01-0.67], abatacept (OR, 0.13; 95% CI, 0.02–0.93), hydroxychloroquine (OR, 0.90; 95% CI, 0.82-0.99), methotrexate (OR, 0.72; 95% CI, 0.64–0.81), cyclosporin (OR, 1.43; 95% CI, 1.07–1.91), nonsteroidal anti-inflammation drugs (NSAIDs) (OR, 1.36; 95% CI, 1.27–1.46), antiplatelet agent (OR, 2.47; 95% CI, 2.31-2.63), hypertension (without anti-hypertensive agents: OR, 1.04; 95% CI, 0.96-1.12; with anti-hypertensive agents: OR, 1.47; 95% CI, 1.36-1.59), diabetes (OR, 1.27; 95% CI, 1.18-1.37), hyperlipidemia without lipid-lowering agents (OR, 1.09; 95% CI, 1.01-1.17), ischemic heart disease (OR, 1.20; 95% CI, 1.10-1.31), and chronic obstructive pulmonary disease (COPD) (OR, 1.12; 95% CI, 1.03-1.23) in the parsimonious model. The risk of MACE in RA patients also increased markedly in participants younger than 65 years with some comorbidities.Conclusions:This population-based case-control study revealed that the use of golimumab, abatacept, hydroxychloroquine, and methotrexate were associated with a decreased risk of MACE development in newly diagnosed RA patients, while the use of cyclosporin, NSAIDs, and antiplatelet agents, and comorbidities, including hypertension, diabetes, hyperlipidemia without lipid-lowering agent therapy, ischemic heart disease, and COPD, were associated with an increased risk of MACE development in RA patients.

O28 Has modern UK management of RA led to a reduction in use of steroids and NSAIDs? 20-year data from the clinical practice research datalink

Abstract Background Over 20 years, rheumatoid arthritis (RA) management has evolved to immediate initiation and more effective escalation of disease-modifying anti-rheumatic drugs (DMARDs) to suppress inflammation. We aimed to establish whether this has facilitated reduced long-term use of potentially toxic glucocorticosteroids (GCs) and nonsteroidal anti-inflammatory drugs (NSAIDs). Methods We investigated changes in DMARD, oral GC and NSAID prescribing over 1998-2017 in a UK primary care electronic health records database. We defined RA by coded diagnosis, sensitivity analyses requiring (a) two diagnoses ≥6 months apart; (b) ≥1 DMARD prescriptions. We calculated annual RA incidence and prevalence, annual prescribing and prescribing in the first to fifteenth year from diagnosis. Long-term prescribing was defined as ≥ 3 months (≥6 in a sensitivity analyses) and compared with a non-RA cohort (5:1 matched on age, sex and GP practice). Results We included 71,411 RA patients (44,426 with 2 diagnoses, 45,438 with DMARD). Incidence declined from 5.01 (±0.36) per 10,000 person-years in 1998 to 4.77 (±0.23) in 2011, before increasing following changes in Quality Outcomes Framework indicators. Prevalence rose from 0.70% (±0.013) in 1998 to 0.91% (±0.014) in 2017 and was highest among patients aged ≥70 (2.21%, ±0.05). Long-term DMARD prescribing rose from 30.97% in 1998 to 49.28% in 2017. Long-term NSAID prescribing fell (45.94% to 25.08%) particularly amongst incident RA patients, with only modest change in GCs (20.98% to 15.53%) (Table 1). By comparison, long-term GC prescribing in the matched non-RA population rose (0.90% to 2.01%) and NSAID prescribing changed little (6.37% to 8.41%). The proportion with long-term prescribing declined slightly from the first to the third year following diagnosis for GCs (22.18% to 17.87%) and NSAIDs (41.19% to 34.30%). Sensitivity analyses showed similar results. Conclusion Long-term GC prescribing among newly diagnosed RA patients has not appreciably reduced despite modern treatment paradigms and the expected observed increase in DMARD prescribing. Long-term NSAID prescribing did decrease in primary care for RA (especially from mid-2000 and among newly diagnosed patients), but interestingly, not for non-RA patients. Given the scope for further reduction in GC and NSAID prescribing, the reasons for persistent prescribing, including prescribing behaviours, require further investigation. Disclosures S.S.R. Crossfield: Grants/research support; Medical Research Council (MRC) Leeds Medical Bioinformatics Centre [MR/L01629X]. M.H. Buch: None. P. Baxter: None. S.R. Kingsbury: Grants/research support; National Institute for Health Research (NIHR) Leeds Biomedical Research Centre and the Versus Arthritis Experimental Osteoarthritis Treatment Centre [20083]. M. Pujades-Rodriguez: None. P.G. Conaghan: Grants/research support; National Institute for Health Research (NIHR) Leeds Biomedical Research Centre and the Versus Arthritis Experimental Osteoarthritis Treatment Centre [20083].

Risk of preventable hospitalization before and after diagnosis among rheumatoid arthritis patients compared to non-rheumatoid arthritis controls.

The purpose of the study is to investigate the risk of preventable hospitalization among patients with rheumatoid arthritis (RA). We identified 11,852 incident RA patients and 59,260 age-, sex-, and index year-matched controls from the Taiwan National Health Insurance Database. Index date was the RA diagnosis date for cases, which was assigned to their matched controls. The odds ratios (OR) of preventable hospitalizations between RA patients and controls were estimated using a mixed effect model adjusted for age, sex, patient characteristics, Elixhauser comorbidity index, medical utilization and regional medical resources. The overall annualized incidence of preventable hospitalization in RA patients and controls was 38.7 vs. 20.9 events per 1,000 person-years (adjusted OR, 1.61; 95% confidence interval [CI], 1.51-1.71). The adjusted OR of preventable hospitalization in RA patients compared to matched controls was 1.17 (1.00-1.37) one year prior to RA diagnosis and remained elevated after RA diagnosis. Adjusted ORs (95% CI) for specific preventable hospitalization categories were 1.93 (1.58-2.36) for chronic obstructive pulmonary disease, 1.64 (1.21-2.21) for asthma, 1.95 (1.78-2.13) for bacterial pneumonia, and 1.59 (1.44-1.75) for urinary tract infection. When assessing the trend of individual preventable hospitalizations before and after diagnosis, bacterial pneumonia and urinary tract infection hospitalizations had a significantly higher OR in RA patients one year before diagnosis and five years afterward (adjusted OR ranges 2.75 to 4.48 and 1.83 to 3.07 respectively, all P-values<0.05) CONCLUSION: RA is independently associated with a higher risk of preventable hospitalization specifically for chronic lung diseases and infections.

Combination effect of anti-rheumatic medications for coronary artery diseases risk in rheumatoid arthritis: a nationwide population-based cohort study

Objectives: To determine whether a combination of anti-rheumatic drugs is associated with the risk of coronary artery diseases (CAD) in incident rheumatoid arthritis (RA) patients.Methods: This population-based cohort study used administrative data to identify 6260 newly-diagnosed patients with RA (age ≥20 years) as the study group. The study end-point was occurrence of CAD according to the ICD-9-CM codes. Exposure to different combinations of drugs and the risk of CAD was assessed. These included different combinatiosn of celecoxib (Cx), hydroxychloroquine (HCQ), methotrexate (MTX), and sulfasalazine (SSZ). Patients who never used Cx, HCQ, MTX, or SSZ were used as a reference group. A Cox proportional hazards model was used to estimate the hazard ratio (HR) of disease after controlling for demographic and other co-morbidities. When the proportionality assumption was violated, the spline curve of the Scaled Schoenfeld residuals was fitted to demonstrate the estimated effect on CAD over time for drug usage.Results: Among RA patients, the adjusted HR (95% confidence interval) of CAD for “Cx only”, “Cx and HCQ ever”, and “Cx, HCQ, MTX, and SSZ ever”, were 0.29 (0.19–0.44), 0.46 (0.24–0.88), and 0.42 (0.24– 0.75), respectively, during the first period of 0–3, 4, or 7 years. However, they became 1.04 (0.78–1.38), 1.16 (0.62–2.19), and 0.59 (0.32–1.08), respectively, during the second time period of 3, 4, or 7–10 years. The adjusted HR (95% CI) of CAD for “Cx, MTX, and SSZ ever” remains constant at 0.12 (0.02–0.89).Conclusions: Celecoxib-DMARDs drug combinations were associated with reduced CAD risk on incident RA patients, and some of them exhibited the time-varying drug effect.

Delay in initiation of DMARD or anti-inflammatory therapy in patients newly diagnosed with rheumatoid arthritis: An analysis of United States Military Health System TRICARE beneficiaries

ObjectiveTo investigate factors associated with delay in initiation of initial disease-modifying antirheumatic drug (DMARD) in patients newly diagnosed with rheumatoid arthritis (RA). MethodsWe performed a retrospective cohort descriptive study using administrative data from the US military's TRICARE program (2007–2012). We identified incident RA cases using billing codes and initial DMARD receipt using prescription fill date. We quantified the time between RA presentation and initial DMARD receipt, evaluated temporal changes in delay over the study period, and investigated predictors of treatment delay (> 90 days) using logistic regression. ResultsWe identified 16,680 patients with incident RA that were prescribed DMARDs and mean age was 47.2 (SD 13.5) years. The mean time from initial RA presentation to first DMARD prescription receipt was 125.3days (SD 175.4). Over one-third (35.6%) of incident RA patients initiated DMARD > 90days after presentation. There was less treatment delay in later years of the study (mean days to DMARD of 144.7days in 2007; 109.7days in 2012). Patients prescribed opioids had mean time to DMARD of 212.8days (SD 207.4) compared to mean of 77.3days (SD 132.3) for those who did not use opioids (p < 0.0001). Patients prescribed opioids between RA presentation and initial DMARD receipt were more likely to have delay in initial DMARD (OR 4.07, 95% CI: 3.78–4.37). ConclusionIn this large US nationwide study, delays in initial DMARD receipt for incident RA were common but time to treatment improved in recent years. While further analysis using clinical data is warranted, these findings suggest that limiting opioid use in patients newly presenting with RA may decrease delay in initiating DMARDs.

The risk of malignancy and its incidence in early rheumatoid arthritis patients treated with biologic DMARDs

BackgroundTreatment with disease-modifying anti-rheumatic drugs (DMARDs) has raised concerns about the risk of malignancies in rheumatoid arthritis (RA) patients. However, the association between biologic DMARDs (bDMARDs) and malignancy in previous reports remains controversial. Therefore we aimed to estimate the incidence of malignancy in early RA patients and to evaluate the relative risk of malignancy with use of bDMARDs.MethodsA retrospective cohort of incident RA patients was established using the Korean National Claims Database. Among a total of 14,081 RA patients identified, 1684 patients with a history of malignancy were excluded. We calculated the incidence rate of overall and individual malignancies. The standardized incidence ratio (SIR) of malignancies in bDMARD users was compared to that in nonusers. Multivariable logistic regression analysis was used to evaluate the impact of bDMARDs on the development of malignancies in early RA patients.ResultsA total of 12,397 early RA patients without a history of malignancy were enrolled. During 41,599 person-years (PY) of follow-up, 725 malignancies developed in 561 patients (174.3/10,000 PY) and 21 hematologic malignancies developed (5.0/10,000 PY). Patients treated with bDMARDs had a significantly lower incidence of overall malignancy compared to those not treated with bDMARDs (SIR 0.45 (95% CI 0.28–0.70)). However, this relationship was not significant with regard to hematologic malignancies (SIR 2.65 (95% CI 0.55–7.76)). On multivariable analysis, bDMARD use was a protective factor against the development of overall malignancy (odds ratio 0.42 (95% CI 0.25–0.73)). However, bDMARD use had no significant protective effect against the development of hematologic malignancies (odds ratio 1.69 (95% CI 0.38–7.59)).ConclusionsIn early RA patients, bDMARD use decreases the overall risk of developing malignancies; however, it does not affect the risk of developing hematologic malignancies.

Association between NICE guidance on biologic therapies with rates of hip and knee replacement among rheumatoid arthritis patients in England and Wales: An interrupted time-series analysis.

To estimate the impact of NICE approval of tumor necrosis factor inhibitor (TNFi) therapies on the incidence of total hip replacement (THR) and total knee replacement (TKR) among rheumatoid arthritis (RA) patients in England and Wales. Primary care data [Clinical Practice Research Datalink (CPRD)] for the study period (1995-2014) were used to identify incident adult RA patients. The age and sex-standardised 5-year incidence of THR and TKR was calculated separately for RA patients diagnosed in each six-months between 1995-2009. We took a natural experimental approach, using segmented linear regression to estimate changes in level and trend following the publication of NICE TA 36 in March 2002, incorporating a 1-year lag. Regression coefficients were used to calculate average change in rates, adjusted for prior level and trend. We identified 17,505 incident RA patients of whom 465 and 650 underwent THR and TKR surgery, respectively. The modeled average incidence of THR and TKR over the biologic-era was 6.57/1000 person years (PYs) and 8.51/1000 PYs, respectively, with projected (had pre-NICE TA 36 level and trend continued uninterrupted) figures of 5.63/1000 PYs and 12.92 PYs, respectively. NICE guidance was associated with a significant average decrease in TKR incidence of -4.41/1000 PYs (95% C.I. -6.88 to -1.94), equating to a relative 34% reduction. Overall, no effect was seen on THR rates. Among incident RA patients in England and Wales, NICE guidance on TNFi therapies for RA management was temporally associated with reduced rates of TKR but not THR.

Temporal Trends in Use of Biologic DMARDs for Rheumatoid Arthritis in the United States: A Cohort Study of Publicly and Privately Insured Patients.

Ten biologic disease-modifying antirheumatic drugs (bDMARDs) are available as treatment for rheumatoid arthritis (RA), but relatively little is known about population-level time trends in the use of these agents. To describe time trends in the use of bDMARDs in RA patients with private or public insurance in the United States. Claims data from private (Optum Clinformatics, 2004-2015) and public (Medicaid Analytic eXtract [MAX], 2000-2010) insurance programs were used. Patients with RA diagnosis codes and continuous health plan enrollment for 1-year baseline and 1-year follow-up periods were identified into 2 separate cohorts: (1) patients not using any bDMARD or (2) patients using a single bDMARD during the baseline period. Initiation of the first bDMARD from group 1 and switch to a second bDMARD from group 2 was identified as the outcome of interest during the 1-year follow-up period. Using mixed-effects regression models, we calculated yearly rates of initiation and switch for bDMARDs, adjusted for case-mix. We also described the proportion of all initiations and switches accounted for by each agent. There were 113,031 RA patients with public insurance and 97,751 RA patients with private insurance who were included in the study. The rates of initiation of bDMARDs (per 100 patients) increased significantly over time in Medicaid data for incident RA patients (from 1.1 to 3.1, P = 0.0006) and prevalent RA patients (from 4.6 to 10.9, P = 0.008). In Optum Clinformatics data, the rates were stable, with 7.7 to 8.3 per 100 incident RA patients (P = 0.10) and 11.0 to 11.5 per 100 prevalent RA patients (P = 0.12). The rates of switching (per 100 patients) increased over time from 6.4 to 16.0 (P = 0.04) in Medicaid data and 9.1 to 17.0 (P = 0.00003) in Optum Clinformatics data. Use of etanercept as the most common first-line agent was stable at approximately 50% of all biologic initiations, but use of infliximab decreased and the use of newer agents increased. More RA patients used bDMARDs in recent years, and use of newer agents, including certolizumab, golumumab, and tocilizuamab, is rising, which highlights a need for further comparative safety and effectiveness research of these agents to better guide evidence-based decision making. This study was supported by an investigator-initiated research grant from Pfizer. The study was conducted by the authors independent of the sponsor. The sponsor was given the opportunity to make nonbinding comments on a draft of the manuscript, but the authors retained the right of publication and determined the final wording. Solomon receives salary support through research support to his hospital from Amgen, Pfizer, AstraZeneca, Genentech, Lilly, Bristol-Myers Squibb, and CORRONA. Kim receives research grants from AstraZeneca, Lilly, Pfizer, Bristol-Myers Squibb, and Genentech. Desai receives research grants from Merck. Study concept and design were contributed by Desai and Kim. Liu took the lead in data collection, along with Jin, Desai, and Kim. All authors contributed equally in the interpretation of the results. The manuscript was written and revised primarily by Desai, along with Kim and the other authors.

Psychiatric and cardiovascular comorbidities as causes of long-term work disability among individuals with recent-onset rheumatoid arthritis

Objectives: With the ameliorating prognosis of rheumatoid arthritis (RA), the role of comorbidities as causes of work disability (WD) may increase. The aim of this study was to determine the contribution of psychiatric and cardiovascular (CV) comorbidities as the leading causes of long-term WD among patients with recent-onset RA.Method: Between 2000 and 2007, all incident, working-age and non-retired RA patients were identified from a Finnish nationwide register. From other registers, we identified the RA patients who were granted a permanent or temporary disability pension by 31 December 2008. The incidences of disability pensions with CV diseases (ICD-10 codes I00–I99) or psychiatric disorders (F20–F69) as the leading causes were assessed and compared with the general population.Results: We identified a cohort of 7831 patients with RA. During follow-up, 1095 patients were granted a disability pension. After adjusting for competing risks, the 9-year cumulative incidence of WD caused by RA, a psychiatric comorbidity, or a CV disease was 11.9, 1.3, and 0.5%, respectively. Compared to the general population, the age- and sex-specific standardized incidence ratio (SIR) of WD due to psychiatric comorbidities was 0.99 [95% confidence interval (CI) 0.80–1.23] and due to CV disease 1.75 (95% CI 1.23–2.51).Conclusions: In the study cohort with recent-onset RA, the 9-year cumulative incidence of disability pensions caused by psychiatric or CV comorbidities was only 11% or 4%, respectively, of that caused by RA itself. Compared to the general population, the risk of WD due to CV disease was increased.

THU0120 Is Early DMARD Use Associated with Less Joint Replacement Surgery? an Analysis of 5,199 Incident Rheumatoid Arthritis (RA) Patients

BackgroundEarly DMARD use in RA may prevent damage and possibly, need for joint replacement.ObjectivesTo assess joint replacements within incident RA patients in Quebec, Canada, and potential associations with early DMARD...

THU0270 Decreased Risk for Severe Persisting Pain in Elderly Patients with Early Rheumatoid Arthritis – Results from the Swedish Population-Based EIRA and SRQ Register

BackgroundPain is common in rheumatoid arthritis (RA), and a significant portion of patients report pain also after adequate disease suppression and achievement of low detectable inflammation. In order to optimize...

Antidepressant use among persons with recent-onset rheumatoid arthritis: a nationwide register-based study in Finland

Objectives: The aim of this study was to investigate antidepressant use in a nationwide cohort of persons with incident rheumatoid arthritis (RA) in 2000–2007 in Finland.Method: Register data from the Social Insurance Institution of Finland were used to evaluate antidepressant use in ≥ 50-year-old incident RA patients (n = 10 356) and the same-age general population.Results: Of the RA patients, 10.0% (n = 1034) had used antidepressants during the year preceding RA diagnosis. The cumulative incidence of antidepressant initiations after RA diagnosis was 11.4% [95% confidence interval (CI) 10.0–12.9] for men and 16.2% (95% CI 14.9–17.5) for women at the end of follow-up (mean 4.4 years). Female gender [age-adjusted hazard ratio (HR) 1.39, 95% CI 1.21–1.60] and increasing number of comorbidities (p for linearity < 0.001) predicted antidepressant initiations. In the last follow-up year, antidepressant use was at the same level among men with RA [prevalence rate ratio (PRR) 0.93, 95% CI 0.82–1.06] but lower among women (PRR 0.89, 95% CI 0.83–0.95) when compared to the general population.Conclusions: Antidepressant initiations in early RA were associated with female gender and comorbidity. Although depression is stated to be a sizeable problem in RA, the prevalence of antidepressant use did not exceed the population level.

Tumor Necrosis Factor α Inhibitor Use and Decreased Risk for Incident Coronary Events in Rheumatoid Arthritis

To determine the association of tumor necrosis factor α (TNFα) inhibitors with risk for cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients. A retrospective cohort of 2,101 incident RA patients was established. Medication exposure was categorized into the following groups: TNFα inhibitors alone or in combination with methotrexate (MTX; aTNF group); MTX alone or in combination with other nonbiologic disease-modifying antirheumatic drugs (DMARDs; MTX group); and no MTX, nonbiologic DMARDs (reference group). Primary outcome was adjudicated incident coronary artery disease (CAD), defined as myocardial infarction, unstable angina, or coronary revascularization procedure. Secondary outcome was adjudicated incident CVD, defined as a composite of CAD, stroke, transient ischemic attack, abdominal aortic aneurysm, peripheral arterial disease, or arterial revascularization procedure. Cox regression models were used to calculate the hazard ratio for CAD and CVD for the aTNF and MTX groups compared to the reference group. There were 46 incident CAD and 82 incident CVD events. Adjusting for covariates associated with CAD and CVD, the hazard ratio for incident CAD was 0.45 (95% confidence interval [95% CI] 0.21-0.96) for the aTNF group and 0.54 (95% CI 0.27-1.09) for the MTX group compared to the reference group. Use of TNFα inhibitors for >16.1 months was associated with a relative risk for CAD of 0.18 (95% CI 0.06-0.50) and for CVD of 0.31 (95% CI 0.15-0.65) compared to the reference group. A similar, although not significant, trend was seen with the MTX group. Use of TNFα inhibitors is associated with a decreased risk for CAD in RA; the risk decreases further with long-term use. This should be considered when weighing the risks versus benefits of these medications.

FRI0410 Rheumatoid arthritis (RA) care: Geographic disparities and impact of primary care physicians on access to rheumatologists

BackgroundEarlier population-based assessments have demonstrated that many Canadians are not provided optimal RA therapy.1 This is especially true for seniors with RA. Little is known about potential barriers that limit...