Your participation in CATCH has allowed the team to look at a lot of data about people who are diagnosed with early rheumatoid arthritis and look at trends over a long period of time, to see what others like you have in common, or to see the most effective way to treat people with medications. The researchers then present these findings to other researchers at national and international scientific meetings - sometimes they give a talk and other times they will give a poster (at scientific meetings there are dedicated poster sessions where researchers really stand by posters that they've made about their research and findings at certain times and then talk to people who come by to read their posters). Researchers have to 'apply' to present their research and work at meetings, and they do that by creating an 'abstract' which is a shortened version of what they wish to present at a meeting.

All of the CATCH team research abstracts are provided here by year. Each abstract is split in to a 'short' version to give you a simple overview of the research, and if you click on the 'read more' section there is a longer version of the abstract with a few more details for you. If the CATCH team has published a scientific paper on this topic, we have also provided a link to the paper for you. We have tried to use simple language so that you can understand what the researchers did and what they found. You may wish to open our Glossary page beside the abstracts as you read them and we have also linked some more difficult terms directly to the Glossary so you can look up these words as you read (those words are shown in dark red).

If you are interested in reading the full scientific papers (also called manuscripts) that have resulted from CATCH research, you can click here and you will be redirected to a page that lists all papers that have been published according to year.

We thank you for your participation in CATCH - none of this research and none of these abstracts would be here without you.


Assessing System-Level Performance Measures for Early Rheumatoid Arthritis in a Large Multicenter Cross-Country Prospective 8-Year Observational Cohort Study

Claire E.H. Barber1, Cheryl Barnabe2, Glen Hazlewood2, Orit Schieir3, Lyne Nadeau4, J Carter Thorne5, Vandana Ahluwalia6, Susan J. Bartlett7, Gilles Boire8, Boulos Haraoui9, Carol Hitchon10, Edward Keystone11, Diane Tin12, Janet E. Pope13, Lisa Denning14, Vivian P. Bykerk15 and Canadian Early Arthritis Cohort (CATCH) Investigators. 1University of Calgary, Calgary; 2Division of Rheumatology, University of Calgary, Calgary; 3Dalla Lana School of Public Health, University of Toronto, Toronto; 4McGill University, Montreal; 5Southlake Regional Health Centre, Newmarket; 6Ontario Rheumatology Association, Brampton; 7Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore; 8Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 9Institute de Rheumatologie, Montreal; 10University of Manitoba, Winnipeg; 11Mt. Sinai Hospital, University of Toronto, Toronto; 12The Arthritis Program, Southlake Regional Health Centre, Newmarket; 13University of Western Ontario, St Joseph's Health Care, London; 14William Osler Health System, Brampton; 15Division of Rheumatology, Hospital for Special Surgery, New York.

The Arthritis Alliance of Canada developed a set of 6 measures to evaluate timely access to care and treatment for inflammatory arthritis. A national study is underway to test these measures. The objective of this study was to look at 3 of these measures in early rheumatoid arthritis patients receiving care in rheumatology clinics participating in CATCH. The measures being studied here are: 1. Percentage of patients with RA seen in a yearly follow-up appointment; 2. Annual percentage of RA patients treated with a disease-modifying drug (DMARD); and, 3. Time from new RA diagnosis to start of DMARD treatment. We found in CATCH, over 8 years, 72% of patients were seen in a yearly follow-up appointment, the yearly percentage of newly diagnosed RA patients on a DMARD ranged between 92-100%, and RA patients who received DMARD treatment within 14 days of diagnosis increased from 74% to 90%. CATCH is a unique research study and our findings may be useful as a benchmark while testing the measures using other settings and research studies.

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What was the purpose of the study?

The Arthritis Alliance of Canada developed a set of 6 measures to evaluate timely access to care and treatment for inflammatory arthritis. A national study is underway to test these measures. The objective of this study was to look at 3 of these measures in early rheumatoid arthritis patients receiving care in rheumatology clinics participating in CATCH.

How was this study done?

This study included ERA patients enrolled between January 1, 2007 and January 31, 2015, who met the 1987 or 2010 ACR/EULAR RA criteria and had symptoms for less than one year. Measures included: 1. Percentage of patients with RA seen in a yearly follow-up appointment, 2. Annual percentage of RA patients treated with a disease-modifying drug (DMARD), and, 3. Time from new RA diagnosis to start of DMARD treatment. 

What were the results of the study?

1927 RA patients were in the study. Over 8 years, 72% of patients were seen in a yearly follow-up appointment. The yearly percentage of newly diagnosed RA patients on a DMARD ranged between 92-100%. Between 2007 and 2015 the percentage of RA patients who received DMARD treatment within 14 days of diagnosis increased from 74% to 90%.

Between 2007-2015 the percentage meeting benchmarks for time to DMARD therapy increased in CATCH from 74% to 90%. A drop-off in yearly follow-up is typical of many observational studies, though less in CATCH, maybe because of universal access to care. The decline in percentage on DMARD over time likely represents a number of factors including: DMARD-free remission associated with earlier diagnosis and treatment, patient engagement and not taking medication as prescribed, and a possible care gap. Analysis of medication use over time is an ongoing goal of this study.

This study represents a best-case scenario for capturing measures from data that were systematically collected and shows the feasibility of quick start of DMARD treatment. Our findings may be useful as a benchmark while testing the measures using other settings and data sources.


Can Oral and Parenteral Steroid in the First Three Months Modify Disease Course in Early RA? Results from the Canadian Early RA Cohort (CATCH)

Kathleen Andersen1, Susan Bartlett2, Daming Lin3, Orit Schieir2, Gilles Boire4, Boulos Haraoui5, Carol Hitchon6, Shahin Jamal7, Ed Keystone8, Janet Pope9, Diane Tin10, Carter Thorne10, Vivian Bykerk111Hospital for Special Surgery, New York; 2McGill University, Montreal; 3Mount Sinai Hospital, Toronto; 4Université de Sherbrooke, Sherbrooke; 5Institut de rhumatologie de Montreal, Montréal; 6University of Manitoba, Winnipeg; 7University of British Columbia, Vancouver; 8Mount Sinai Hospital, University of Toronto, Toronto; 9University of Western Ontario, St Joseph's Health Care, London; 10Southlake Regional Health Centre, Newmarket; 11Hospital for Special Surgery, New York.

We looked at whether steroid use and how steroids were taken in the first 3 months of being in CATCH were associated with progression to biologic therapies at 12 and 18 months. Patients receiving steroids within the first 3 months were older, had more active RA, and had their symptoms for less time. Despite use of both oral and parental (that means injected) steroids, these patients were more likely to require biologics at both 12 and 18 months. While steroids may improve symptoms in the short to medium term, results suggest they may not change long-term disease course in early RA.

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What was the purpose of the study?
Steroid use in early RA can help decrease swelling and pain, allowing DMARDs (which act slower) time to reduce disease activity. Steroid use in early RA is variable, though several reports have suggested that combining low dose oral steroids with DMARDs can reduce joint damage. This study looked at whether steroid use and how steroids are given in the first 3 months of CATCH were associated with patients moving on to biologic therapies at 12 and 18 months.

How was this study done?
Data are from the first 18 months of patients entering CATCH and included participants with symptoms for less than or equal to 13 months, who were diagnosed with RA using the ACR 1987 and/or 2010 RA criteria, who were not on biologics in the first 3 months, and had complete information available on biologic, steroid, and methotrexate use. Patients were grouped according to steroid use (none, intra-articular/intra-muscular, oral, or intra-articular/intra-muscular and oral) within the first 3 months.

What were the results of the study?
At the study start, there were 1481 patients, and the 877 (or 59%) of patients on steroids for treatment were older and unemployed, had more comorbidities, had shorter symptom duration, and were from larger sites, but did not differ by sex, race, body mass index, or education. Steroid users had significantly higher scores for patient-reported outcomes (including the patient global, pain, fatigue, and HAQ scores) and clinical characteristics (including the physician global, joint counts, DAS28 and CDAI). Higher scores on these scales indicate more active RA. At 12 months, 126 patients were on biologics and at 18 months, 159 were on biologics. Patients receiving steroids had significantly greater odds of being on biologics at 12 and 18 months.

Patients receiving steroids within the first 3 months were older, had more active RA, and shorter symptom duration. Despite use of injected and oral steroids, they were more likely to require biologics at both 12 and 18 months. While steroids may improve symptoms in the short and medium term, results suggest they may not change long-term disease course in early RA.


Cardiovascular Disease in the Canadian Early Arthritis Cohort

Lillian Barra1, Janet Pope2, Carol Hitchon3, Gilles Boire4, Kyle Arsenault-Mehta1, Orit Schieir5, Daming Lin6, Carter Thorne7, Diane Tin7, Ed Keystone8, Boulos Haraoui9, Vivian Bykerk10, CATCH Canadian Early Arthritis Cohort11. 1The University of Western Ontario, London; 2University of Western Ontario, St Joseph's Health Care, London; 3University of Manitoba, Winnipeg; 4Université de Sherbrooke, Sherbrooke; 5McGill University, Montreal; 6Mount Sinai Hospital, Toronto; 7Southlake Regional Health Centre, Newmarket; 8Mount Sinai Hospital, University of Toronto, Toronto; 9Institut de rhumatologie de Montreal, Montréal; 10The Hospital for Special Surgery, New York; 11Toronto.

The CATCH researchers wanted to estimate the incidence and predictors of cardiovascular disease (CVD) since rheumatoid arthritis (RA) has been associated with an increased risk of CVD. While some people in CATCH had CVD before they started the study, some people developed CVD after they started CATCH. Results showed that patients who had RA for a long time had a greater risk of developing CVD, otherwise a person's risk of developing CVD was influenced by the same risk factors that affect people who do not have RA. These factors include age, being male, and using non-steroidal anti-inflammatory drugs (NSAIDs) other than naproxen.

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What was the purpose of the study?
Rheumatoid Arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD). This study's purpose was to estimate the incidence and predictors of CVD in the CATCH cohort.

How was this study done?
The CATCH researchers defined CVD as: a sudden coronary event, surgery for coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease requiring surgery or death secondary to CVD. Information on already-existing CVD and risk factors and medications for CVD was collected at the start of the study. CVD events and cardiac medications taken by patients after enrolling in CATCH were self-reported by patients. A medical record review was done on a small number of patients to ensure that self-reported events did match their medical records. There was good agreement between self-reported variables for 141 patients and medical records.

What were the results of the study?
Of 2652 patients in CATCH, there were 55 new CVD events and the overall frequency of CVD was 2.2%. Predictors of CVD that were independent of a person having arthritis were age, being male, high blood pressure, and taking cyclooxygenase-2 (COX-2) inhibitors or other non-steroidal anti-inflammatories (NSAIDs), except naproxen. The only arthritis-related factor significantly associated with CVD incidence was how long a person had arthritis. Other factors such as RA disease activity and physical function scores, erosive disease, autoantibodies and increases in inflammatory blood markers were not significantly associated with CVD. Interesting, less than a quarter of participants with CVD indicated they were taking aspirin or fat-lowering drugs to help them.

Cardiovascular events were associated with traditional CVD risk factors, duration of RA symptoms prior to enrollment in CATCH, and the use of NSAIDs other than naproxen.


Coming Full Circle with the OMERACT RA Flare Questionnaire (RA-FQ): Further Evaluation of the Properties, Meaningfulness, and Utility through Rasch Analysis and Feedback from RA Patients

Susan J. Bartlett1,2, Skye Barbic3, Vivian P. Bykerk4, Bruno Fautrel5, Francis Guillemin6, A den Broeder7, R Alten8, Robin Christensen9, Ernest H. Choy10, Daniel E. Furst11, Sarah Hewlett12, Amye L. Leong13, Lyn March14, Thasia G Woodworth15, Clifton Bingham III16 and OMERACT Flare Group and Canadian Early Arthritis Cohort (CATCH) Investigators. 1Department of Medicine, Division of Clinical Epidemiology, Rheumatology, Respirology, McGill University, Montreal, 2Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, 3University of British Columbia, Vancouver,4Division of Rheumatology, Hospital for Special Surgery, New York, 5Rheumatology, AP-HP Pitié-Salpêtrière Hospital / Pierre and Marie Curie University Paris 6 GRC-08 (EEMOIS), Paris; 6University of Lorraine, Nancy, France, 7Rheumatology, Maartenskliniek, Nijmegen, Netherlands, 8Schlosspark-Klinik University Medicine, Berlin; 9The Parker Institute, RC, Copenhagen; 10Section of Rheumatology, Cardiff University, Cardiff; 11University of California, Los Angeles, Los Angeles; 12Academic Rheumatology, University of West of England, Bristol; 13Spokesperson; Strategic Relations, BONE AND JOINT DECADE, Santa Barbara; 14Department of Rheumatology, Northern Clinical School, Institute of Bone and Joint Research, Kolling Institute, University of Sydney & Department of Rheumatology, Royal North Shore Hospital, St Leonards, Sydney; 15Leading Edge Clinical Research, Stuart; 16Johns Hopkins University, Baltimore.

Outcome Measures in Rheumatology (also called OMERACT for short) encourages development of new measures with robust methods. Measurement tool results should be highly relevant, easy to score and interpret, and meaningful to stakeholders who will use the tool. We did an analysis to explore the psychometric aspects of the OMERACT RA Flare Questionnaire (RA-FQ). We reviewed the results with RA patient research partners for insight about the interpretability, meaningfulness, and utility of results. There was complete agreement from the patients that the story depicted and their individual results were easy to understand, meaningful, and very reflective of their current state. Many patients noted that beyond clinical trials, the RA-FQ could also help with communication between doctors and patients at routine visits. Several noted that the results could also help them understand their RA's day-to-day status and with their own self-management.

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What was the purpose of the study?

Outcome Measures in Rheumatology (also called OMERACT for short) encourages the development of new measures with robust methods. Measurement tool results should be highly relevant, easy to score and interpret, and meaningful to stakeholders who will use the tool. We did an analysis to explore the psychometric properties of the OMERACT RA Flare Questionnaire (RA-FQ). We reviewed results with RA patient research partners for insight into the interpretability, meaningfulness, and utility of results.

How was this study done?

People with RA in Canada (896 patients), France (138 patients), and the Netherlands (178 patients), completed 5 items representing each of the OMERACT RA flare core domains. We evaluated how the five items worked together as well as reliability, response options, redundancy, local dependence, and response bias among groups (for example, men versus women, age categories, country and language). Ten patient research partners first completed the questionnaire, then reviewed individual and group findings to provide feedback.

What were the results of the study?

Our analysis showed that the 5 items are acceptable to measure RA flare symptoms and impacts by summing each item’s score for a total score ranging from 0-50. The five items and total scores did not differ depending on a respondent’s sex, age, country or language. Items suggest flare symptoms and impacts increased together and showed a consistent story of how individuals experience worsening RA disease activity. There was unanimous agreement from the patients that the story depicted and individual results obtained were easy to understand, meaningful, and very reflective of their current state. Many patients noted that beyond clinical trials, the RA-FQ could also help communication between doctors and patients at routine visits. Several noted that the tool would also be helpful in monitoring their RA’s day-to-day status and with self-management.


Comparing Initial Treatment Strategies With Methotrexate On First Use Of Biologic Therapy: Results From The Canadian Early Arthritis Cohort

S. Gottheil1, J. Pope2, O. Schieir3, G. Hazlewood4, E. Keystone5, S. Jamal6, C. Barnabe4, G. Boire7, C. Hitchon8, C. Thorne9, V. Bykerk5, D. Tin9, P. Haraoui10 and CATCH Investigators.

1London Health Sciences Centre; 2St. Joseph's Health Care, London; 3University of Toronto, Toronto; 4University of Calgary, Calgary; 5Mount Sinai Hospital, Toronto; 6University of British Columbia, Vancouver; 7Sherbrooke University, Montreal; 8University of Manitoba, Winnipeg; 9Southlake Regional Health Centre, Newmarket; 10University of Montreal, Montreal.

The CATCH researchers wanted to see if there was a difference in time for patients to take a biologic if they started treatment with methotrexate alone or with other DMARDs. 1214 patients were followed over 3 years to see if they started a biologic - 212 of them went on to a biologic. Initial methotrexate use included: pill form alone was used as starting treatment in 230 (or 19%) patients, injected form in 226 (or 19%) patients, and methotrexate with other DMARDs in 730 (or 62%) of patients. Patients who injected methotrexate alone were half as likely to require biologics compared to patients who started with methotrexate in pill form. The researchers are not sure why this is the case, but think that methotrexate that is injected might work better than the pill form. For patients who took methotrexate in pill form or methotrexate with other DMARDs, there was no difference in how long it took them to start a biologic.

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What was the purpose of the study?
Optimal treatment of early rheumatoid arthritis involves a strategy called treat-to-target that aims to help patients get to remission. Patients with early RA who start treatment with a combination of DMARDs have increased chances of remission. Also, research shows that combinations of DMARDs can provide the same outcomes as biologic DMARDs. Biologics cost significantly more than other DMARDs. The CATCH researchers wanted to see if there was a difference in time for patients to take a biologic if they started treatment with methotrexate alone or with other DMARDs.

How was this study done?
Patients in the study had RA and their symptoms for less than one year and patients treated with a biologic at the study start were not included. Patients were followed over 3 years to see if they started a biologic. The researchers examined the effects of methotrexate in pill form alone, methotrexate that was injected alone, and methotrexate taken with other DMARDs.

What were the results of the study?
1214 patients were in the study, and 212 of them went on to require the use of biologics. For starting treatment, 230 (or 19%) took methotrexate in pill form only, 226 (or 19%) of them took methotrexate by injection only, and 730 (62%) of them took methotrexate with other DMARDs.

The researchers found that patients who injected methotrexate and did not take other DMARDs were half as likely to require biologics as patients who took methotrexate in pill form only. There was no difference in time to a biologic between methotrexate taken with other DMARDs or methotrexate taken in pill form only.

The researchers found that patients who injected methotrexate alone had a reduced use of biologics. They think that injected methotrexate might work better than methotrexate in the pill form, and thus also delays the need for biologic therapies.


Does Early Steroid Use Increase the Likelihood of Achieving Remission at 6 Months in Early RA? Results from the Canadian Early Arthritis Cohort

K. M. Andersen*1 on behalf of CATCH Investigators, S. J. Bartlett2,3, D. Lin4, O. Schieir5, G. Boire6, B. Haraoui7, C. Hitchon8, S. Jamal9, E. Keystone4, J. Pope10, D. Tin11, C. Thorne11, V. P. Bykerk1,12 and CATCH Investigators.

1Rheumatology, Hospital for Special Surgery, New York; 2Johns Hopkins University, Baltimore; 3McGill University, Montreal; 4Mount Sinai Hospital; 5University of Toronto Dalla Lana School of Public Health, Toronto; 6Universite de Sherbrooke, Sherbrooke; 7Institut de Rheumatologie, Montreal; 8University of Manitoba, Winnipeg; 9University of British Columbia, Vancouver; 10University of Western Ontario, London; 11Southlake Regional Health Center, Newmarket; 12Rheumatology, Mount Sinai Hospital, Toronto.

The CATCH researchers wanted to understand how often steroids were used in a group of patients with early rheumatoid arthritis and to understand how steroid use is related to achieving remission in patients within 6 months of their diagnosis with RA. Out of 1170 patients, 640 (or 55%) of patients used steroids (which they took as pills, injected or did both) when they were diagnosed. Patients receiving steroids were older; male; and, had symptoms for less time, a higher disease activity, and more swollen and tender joints. Steroids were most commonly used with methotrexate as a treatment. At 6 months, 34% of the patients who used steroids were in remission. While remission was not affected by how a person took steroids, people who took both pills and injected steroids had lower chances of being in remission.

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What was the purpose of the study?

Patients often use steroids (also called synthetic glucocorticoids) to quickly ease their RA symptoms while giving slower acting disease modifying anti-rhuematic drugs (DMARDs) time to take affect. It is not known how or if the early use of steroids with DMARDs affects achieving early remission. The CATCH researchers wanted to understand the frequency of steroid use in a group of patients with early rheumatoid arthritis and to understand how that use is related to achieving remission in patients as early as 6 months after their diagnosis with RA.

How was this study done?

Data from patients in the CATCH study were examined at the start of the study and 6-months. Patients were diagnosed with RA, had symptoms for less than or equal to 1 year, had moderate to high disease activity (measured by the DAS28) at the study start, and had medication information and DAS28 scores at 6 months.

Of 1170 CATCH participants at the beginning of the study, 640 (or 55%) patients used steroids (which 264 took as pills; 295 injected; and 81 took both forms). Patients receiving steroids were older, male, had symptoms for a shorter amount of time, had  higher disease activity, and had more swollen and tender joints.

What were the results of the study?

The researchers found that 80% of the time, steroids were used with methotrexate, including:

  • 30% of the time patients were taking only methotrexate;
  • 50% of the time patients were on a combination of methotrexate and another DMARD;
  • 2% of the time patients were taking biologics (2% of the time); and,
  • 18% of the time patients were on other treatments.

At 6 months, 393 (or 34%) of patients taking steroids were in remission as defined by the DAS28 score. Neither pill nor injected steroids alone were associated with remission at 6 months, though patients who took steroids in both pill and injected forms did have a lower chance of being in remission.


Early Inflammatory Arthritis Presentation, Management and Outcomes in Canadian Aboriginal Patients

Sujay Nagaraj1, Cheryl Barnabe2, Orit Schieir3, Vivian P. Bykerk4, Janet Pope5, Shahin Jamal6, Gilles Boire7, Edward Keystone8, Diane Tin9, Boulos Haraoui10, J Carter Thorne11, Carol Hitchon12 and Canadian Early Arthritis Cohort (CATCH) Investigators. 1McCaig Institute for Bone and Joint Health, University of Calgary, Calgary; 2Division of Rheumatology, University of Calgary, Calgary; 3Dalla Lana School of Public Health, University of Toronto, Toronto; 4Divison of Rheumatology, Hospital for Special Surgery, New York; 5University of Western Ontario, St Joseph's Health Care, London; 6University of British Columbia, Vancouver; 7Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 8Mt. Sinai Hospital, University of Toronto, Toronto; 9The Arthritis Program, Southlake Regional Health Centre, Newmarket; 10Institute de Rheumatologie, Montreal; 11Southlake Regional Health Centre, Newmarket; 12University of Manitoba, Winnipeg.

Differences in access to care that affect the timing and quality of treatment may result in differences in outcomes between Aboriginal and Caucasian patients with inflammatory arthritis. Our study compares Aboriginal and Caucasian patients in how RA shows up as symptoms (called presentation), treatment strategy, and outcomes over five years. We observed differences in how RA looks in Aboriginal patients and worse RA outcomes, even though the same approach to treatment was used as that in Caucasian patients. These differences may be a result of differences in socioeconomic status and in environmental exposures that we know are associated with worse RA outcomes.

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What was the purpose of the study?

Differences in access to care that affect the timing and quality of treatment interventions may create outcome differences for Aboriginal and Caucasian patients with inflammatory arthritis. To see if this is the case, our study compared Aboriginal and Caucasian patients in how RA shows up as symptoms (called presentation), treatment strategy, and outcomes over five years.

How was this study done?

Participants in CATCH were part of this study if they had symptoms for less than one year, identified themselves as Aboriginal or Caucasian, and had at least one follow up visit. A number of factors were compared between Aboriginal and Caucasian participants, including their baseline demographics, clinical characteristics, and therapy changes for moderate or high disease activity states. Therapy changes were defined as increased dose of methotrexate, addition of a DMARD, and/or addition or switching biologic. The frequency of remission and use of DMARD, biologic and steroid therapy were also compared between groups.

What were the results of the study?

There were 2173 patients in total, of which 100 were Aboriginal. Of these patients, 70% were female with an average age of 54 years. Differences in current smoking status, body mass index, education, and household income disfavoured Aboriginal patients. Aboriginal patients were more frequently seropositive and less likely to have erosions at baseline, but did not differ in symptom duration, number of comorbid conditions, or baseline HAQ and DAS28. Therapy was escalated at about 50% of visits where patients were in moderate disease activity state and 60% of visits where patients were in high disease activity state, with no differences between groups in the frequency or type of treatment strategy used. DAS28 remission was less frequent in Aboriginal patients at all visits up to 3 years and can be broken down as follows:

  • 3 months: 16% of Aboriginals were in remission versus 30% of Caucasians in remission,
  • 12 months: 16% of Aboriginals were in remission compared to 50% of Caucasians in remission, and
  • 3 years: 40% of Aboriginal patients were in remission compared to 59% of Caucasians.

This was driven by higher values for all disease activity factors in Aboriginal patients, for example, swollen joint counts in Aboriginal patients improved at a significantly slower rate and patient global scores did not improve significantly in Aboriginal patients. This means that overall, Aboriginal patients had worse RA disease activity than Caucasian patients.

We observed differences in the display of RA symptoms in Aboriginal patients compared to Caucasian patients, and worse disease outcomes despite having a treatment strategy similar to the Caucasian population. We think this may be a result of differences in socioeconomic status and in environmental exposures related to worse RA outcomes.


Early Use of Subcutaneous Methotrexate Monotherapy Versus Methotrexate Oral or Combination Therapy Significantly Delays Time to Initiating Biologics in Early RA

Stephanie Gottheil1, J Carter Thorne2, Orit Schieir3, Gilles Boire4, Boulos Haraoui5, Carol Hitchon6, Diane Tin7, Cheryl Barnabe8, Glen Hazlewood8, Edward Keystone9, Vivian P. Bykerk10, Janet E. Pope11, Susan J. Bartlett12 and Canadian Early Arthritis Cohort. 1University of Western Ontario, London; 2Southlake Regional Health Centre, Newmarket; 3McGill University, Montreal; 4Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 5Institute de Rheumatologie, Montreal; 6University of Manitoba, Winnipeg; 7The Arthritis Program, Southlake Regional Health Centre, Newmarket; 8Division of Rheumatology, University of Calgary, Calgary; 9Mt. Sinai Hospital, University of Toronto, Toronto; 10Division of Rheumatology, Hospital for Special Surgery, New York; 11University of Western Ontario, St Joseph's Health Care, London; 12Department of Medicine, Division of ClinEpi, Rheumatology, Respirology, McGill University, Montreal.

The strategy to treat moderate to severe early rheumatoid arthritis involves using methotrexate and aiming for remission. Achieving remission without using drugs called biologics may be preferred because of their high cost and the potential infection risks that biologic use carries. This study compared the length of time it took for people with RA to start to use a biologic when they started treatment with oral methotrexate (that is in pill form) as a single therapy (also called monotherapy) versus subcutaneous methotrexate (injected under the skin) as a single therapy (also called monotherapy) versus methotrexate used in combination with other drugs (also called combination therapy). The study found that starting treatment with subcutaneous methotrexate alone delayed time to requiring the use of a biologic. This may be due to this injected methotrexate working better compared to methotrexate taken as pills. Combination DMARD therapy was not associated with longer time to starting a biologic, potentially because of provincial health regulations that require a trial of combination DMARD therapy before starting biologics. This study suggests that early use of subcutaneous methotrexate can potentially delay the need for biologic therapies.

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What was the purpose of the study?

The strategy to treat moderate to severe early rheumatoid arthritis involves using methotrexate and aiming for remission. Achieving remission without using drugs called biologics may be preferred because of their high cost and the potential infection risks that their use carries. This study compared the length of time it took for people with RA to start to use a biologic when they started treatment with oral methotrexate (in pill form) as a single therapy (also called monotherapy) versus subcutaneous methotrexate (injected under the skin) as a single therapy (also called monotherapy) versus methotrexate used in combination with other drugs (also called combination therapy).

How was this study done?

To be in this study, participants in CATCH needed to meet the 1987 or 2010 ACR criteria for RA, have RA symptoms for less than one year, have moderate or high disease activity as measured by the DAS28 at the start of the study, and be treated with methotrexate. Patients treated with a biologic at the study start were not part of the study. Patients were followed until they started a biologic, or over the timeframe of 3 years.

What were the results of the study?

1189 patients were in the study, and there were 212 patients that started a biologic. At study start, 71% were female with an average age of 54 years, had symptoms for 6 months, and had moderate to high disease activity. In participants, 20% started on oral methotrexate only, 20% started on subcutaneous methotrexate only, and 60% started on methotrexate combination therapy.

Patients treated with subcutaneous methotrexate monotherapy had a significantly delayed time to using a biologic, while there was no difference in the time to start a biologic between methotrexate combination therapy and oral methotrexate monotherapy. Factors that predicted the use of biologics included those who: were a younger age, used corticosteroids, had longer symptom duration, and had higher starting disease activity.

It is thought that treatment with subcutaneous methotrexate monotherapy was associated with a delayed time to biologics because of the treatment working better compared to oral methotrexate. Combination methotrexate therapy was not associated with delay in starting a biologic, but this might be because of provincial health regulations that require a trial of combination DMARD therapy before being allowed to start a biologic. This study suggests that early use of subcutaneous methotrexate can potentially delay the need for biologic therapies.


How Much of a Barrier is Excess Weight and Smoking for Achieving Sustained Remission in Early RA? Results from the Canadian Early Arthritis Cohort

S. J. Bartlett*1,2, O. Schieir3, E. Schulman4, S. M. Goodman4, M. Zhang4, D. Lin5, K. M. Andersen4, G. Boire6, B. Haraoui7, C. Hitchon8, S. Jamal9, E. Keystone5, J. Pope10, D. Tin11, J. C. Thorne11, V. P. Bykerk4,5 and CATCH Investigators

1McGill University, Montreal; 2Johns Hopkins School of Medicine, Baltimore; 3University of Toronto, Toronto; 4Hospital for Special Surgery, New York; 5Mt. Sinai Hospital, Toronto; 6Universite de Sherbrooke, Sherbrooke; 7Universite de Montreal, Montreal; 8University of Manitoba, Winnipeg; 9University of British Columbia, Vancouver, 10Western University, London; 11Southlake Regional Health Center, Newmarket.

The CATCH researchers wanted to see if there was a relationship between excess weight and smoking on achieving sustained remission in patients with early RA. To be in the study, patients with RA had to have symptoms for less than one year, were not in remission at the study start, and had body mass index (BMI) and at least 2 consecutive disease activity scores (DAS28) available. Sustained remission was defined as having a specific DAS28 score or lower at two back to back visits. The proportion of patients in sustained remission rose steadily; at 3 years 408 (or 38%) out of 1,008 patients, had achieved sustained remission. BMI and smoking were significantly associated with sustained remission, and there was a relationship between BMI class, smoking, and gender.

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What was the purpose of the study?
Little is known about whether and/or to what extent lifestyle factors such as excess weight and smoking impact the ability to achieve sustained remission in people living with RA. Weight and smoking are considered to be factors that can be controlled by a person.

How was this study done?
To be included in the study, patients experienced symptoms for less than one year, were not in remission at the start of the study, and had a body mass index (BMI) and at least 2 consecutive DAS28 scores available. Sustained remission was defined as DAS28 less than 2.6 at two back to back rheumatology visits. Independent effects of BMI class (where normal weight is BMI of 18.5-24.9, overweight is BMI of 25-2.9, and obese is BMI of 30 and higher) and smoking on time to sustained remission were estimated.

What were the results of the study?
There were 1,008 patients in the study, who on average were 53 years old, had symptoms for 5 months, and had DAS28 of 5.3 at the study start. There were 728 (or 72%) female patients and 813 (or 81%) were Caucasian. In males, 131 (or 47%) were overweight, 93 (or 33%) obese, and 55 (or 20%) smoked. Of the females, 220 (or 30%) were overweight, 241 (or 33%) obese, and 109 (or 15%) smoked. At the start of the study, 741 (or 74%) patients were treated with methotrexate (alone or with another DMARD), only 28 (or 3%) were on a biologic, and 522 (or 52%) were taking steroids.

The proportion of patients in sustained remission increased with time; at 3 years 408 (or 38%) had achieved sustained in around 11 months. BMI class and smoking status were significantly associated with sustained remission, and there was also a relationship amongst BMI class, smoking, and gender.

The average patient (male or female) in the study was 53-years old, Caucasian, had some postsecondary education, experienced symptoms for 5 months, had 2 comorbidities, a DAS28 of 5, and started treatment with methotrexate and steroids. A non-smoking male with a healthy BMI and these average patient characteristics would have a 41% probability of achieving sustained within 3 years while an obese male smoker's probability of achieving sustained remission in 3 years would only be 15%. An average patient who is a non-smoking female with a healthy BMI would have a 27% probability of achieving sustained remission within 3 years while an obese female smoker's probability of achieving sustained remission would only be 10%. Weight and smoking are important factors that people with RA can control themselves and can have a significant impact on their ability to achieve sustained remission.


Longitudinal Trajectories of the Weighted Lansbury Articular Indices and Standard Joint Counts Are Similarly Correlated with Trajectories of Physical Function in Early Inflammatory Arthritis

Siok Hoon Lily Lim1, Susan J. Bartlett2, Gilles Boire3, Boulos Haraoui4, Edward Keystone5, J Carter Thorne6, Janet E. Pope7, Diane Tin8, Vivian P. Bykerk9, Carol Hitchon10 and Canadian Early Arthritis Cohort (CATCH). 1Pediatrics, University of Manitoba, Winnipeg; 2Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore; 3Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 4Institute de Rheumatologie, Montreal; 5Mt. Sinai Hospital, University of Toronto, Toronto; 6Southlake Regional Health Centre, Newmarket; 7University of Western Ontario, St Joseph's Health Care, London; 8The Arthritis Program, Southlake Regional Health Centre, Newmarket; 9Division of Rheumatology, Hospital for Special Surgery, New York; 10University of Manitoba, Winnipeg.

Residual RA disease activity affects the functional abilities of people with RA as well as their quality of life (QoL). Large weight bearing joints are more likely to impact abilities to function (for example walking) than small non-weight bearing joints, although the effects may vary from task to task. The Lansbury Articular Index (LAI) is a measurement tool that weights large joints more than small joints so may give a better estimate of overall disease burden with respect to using large joints. On the other hand, the Health Assessment Questionnaire (HAQ) weighs upper extremity tasks more than lower extremity or weight bearing tasks and asks questions about overall functional abilities. We set out to determine associations of LAI with HAQ, QoL and baseline disability status, and whether changes in the LAI trajectory more closely reflected the evolution of the HAQ trajectory than the standard joint count measures. The trajectories of function (HAQ) and both Lansbury and standard joint counts are highly correlated over time in early RA. The LAI performed similarly to standard joint counts, which are easier to determine. Although type of occupation was not addressed and likely influences the impact of lower extremity involvement, tender joint count is associated with baseline work disability.

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What was the purpose of the study?

Residual RA disease activity impacts a person’s ability to function and their quality of life (QoL). Large weight bearing joints are more likely to impact function, such as walking, than small non-weight bearing joints, although the effect may be different depending on the ask. The Lansbury Articular Index (LAI) is a tool that weights large joints more than small joints and so may estimate overall disease burden with respect to large joint function. The Health Assessment Questionnaire (HAQ) weighs upper extremity tasks more than lower extremity or weight bearing tasks. We wanted to determine associations of LAI with HAQ, QoL and baseline disability status and whether changes in the LAI trajectory more closely reflected the evolution of the HAQ trajectory than the standard joint count measures.

How was this study done?

Participants in CATCH were part of the study if they had arthritis activity measures (DAS28, tender 28 joint count (TJC28), swollen 28 joint count (SJC28), function (Health Assessment questionnaire; HAQ) quality of life (SF12 physical (PCS) and mental (MCS) indices) and work status available. The LAI based on 28 joints was calculated separately for swollen (LS28) and tender (LT28) joint counts. A number of analyses were performed.

What were the results of the study?

Participants were followed over two years, and combining all visits, the LS28 strongly correlated with SJC28, PCS, and HAQ. The LT28 correlated with the TJC28, PCS, and HAQ. Correlations were even stronger with the full LAI (42 joints). Disability or sick leave at the study start (which was 6% of participants) was associated with higher LT28 and higher TJC28 (which generally means worse RA activity). The HAQ over time was highly correlated with the trajectories for DAS28, LT28, and TJC28, and less strongly with trajectories for LS28 and SJC28.

The measurements of function (HAQ) and both Lansbury and standard joint counts are highly correlated over time in ERA. The LAI performed similarly to standard joint counts which are easier to determine. Although type of occupation was not addressed and likely influences the impact of lower extremity involvement, both LT28 and TJ28 associated with baseline work disability.


Longitudinal Trajectories of the Weighted Lansbury Articular Indices and Standard Joint Counts Are Similarly Correlated with Trajectories of Physical Function in Early Inflammatory Arthritis

Lily Lim1, Susan Bartlett2, Gilles Boire3, Boulos Haraoui4, Edward Keystone5, Janet Pope6, Carter Thorne7, Diane Tin7, Vivian Bykerk8, Carol Hitchon1, Canadian Early Arthritis Cohort (CATCH) Investigators

1University of Manitoba, Winnipeg; 2McGill University, Montreal, 3Université de Sherbrooke, Sherbrooke; 4Institut de Rhumatologie de Montreal, Montréal; 5Mount Sinai Hospital, University of Toronto, Toronto; 6Western University, London; 7Southlake Regional Health Centre, Newmarket; 8Hospital for Special Surgery, New York.

Lansbury Articular Index (LAI) weights joints by size, allowing estimates of the disease burden of large joints. The Health Assessment Questionnaire (HAQ) seems to weigh upper extremity tasks more than lower extremity or weight-bearing tasks. The scores over time of HAQ and Lansbury and standard joint counts are highly correlated in early RA. The LAI performed similarly to standard joint counts. Although type of job a person hold was not addressed and likely influences the impact of lower extremity involvement, both LT28 and TJ28 were associated with work disability at the start of the study.

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What was the purpose of the study?

Lansbury Articular Index (LAI) weights joints by size, allowing estimates of the disease burden of large joints. The Health Assessment Questionnaire (HAQ) seems to weigh upper extremity tasks more than lower extremity or weight-bearing tasks. The researchers wanted to determine associations of LAI with HAQ and whether changes in the LAI trajectory more closely reflected the evolution of the HAQ trajectory than the standard joint count measures.

How was this study done?

We used data from CATCH. Arthritis activity measures (DAS28, tender28 joint count (tjc28), swollen 28 joint count (sjc28), function (HAQ), quality of life (SF12 physical (PCS) and mental (MCS) scores) and work status were looked at. The LAI based on 28 joints was calculated for swollen (LS28) and tender (LT28) joint counts. The impact of LS28, LT28 on disability status at the study start was modeled. Individuals’ changes for each measure (HAQ, DAS28, TJC28, SJC28, LT28,LS28) over time were examined. Correlations between each pair of joint trajectories (HAQ with TJC28 or SJC28 or LT28 or LS28) were calculated.

What were the results of the study?

On average, participants in the study had 2 years of follow up data and at the last visit 44% of participants were in remission. Combining all visits, the LS28 correlated with SJC28, PCS and HAQ. The LT28 correlated with the TJC28, PCS, and HAQ. 6% of participants experienced work disability at the start of the study and work disability was associated with higher LT28 and higher TJC28. The HAQ score over time was highly correlated with the scores over time for DAS28, LT28, and TJC28 and less strongly with scores over time for LS28 and SJC28.

The scores over time of HAQ and both Lansbury and standard joint counts are highly correlated in early RA. The LAI performed similarly to standard joint counts. Although the type of job that a participant held was not addressed and likely influences the impact of lower extremity involvement, both LT28 and TJ28 associated with work disability at the start of the study.


No Escalation of Therapy Despite High Disease Activity in the CATCH Cohort

Stephanie Garner1, Cheryl Barnabe1, Gilles Boire2, Carol Hitchon3, Ed Keystone4, Boulos Haraoui5, Carter Thorne6, Diane Tin6, Janet Pope7, Vivian Bykerk81University of Calgary, Calgary; 2Université de Sherbrooke, Sherbrooke; 3University of Manitoba, Winnipeg; 4Mount Sinai Hospital, University of Toronto, Toronto; 5Institut de rhumatologie de Montreal, Montréal; 6Southlake Regional Health Centre, Newmarket; 7University of Western Ontario, St Joseph's Health Care, London; 8Hospital for Special Surgery, New York.

This study looked at how closely rheumatologists used a well-known treatment practice in early arthritis called treat to target. Treat to target involves closely watching patients with early arthritis over many visits and increasing medications as necessary based on their RA disease activity. Of patients with moderate or high disease activity at three months who did not have an escalation of therapy, just under half of them were on DMARD combination therapy. The percentage of erosions in this group increased over time, which is an important indicator of RA not being completely under control. The reasons why these patients with moderate to high disease activity did not receive an escalation of therapy require more investigation. These results could show that more effort is required to apply a treat to target approach.

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What was the purpose of the study?
The standard of care for the treatment of RA is early aggressive therapy with a treat to target approach (which means treating a person with the aim of remission). Meeting this standard requires frequent follow-up and increase of therapy as necessary. The purpose of this study was to look at the adherence by rheumatologists to treat to target by evaluating treatment escalation with respect to to RA disease activity state.

How was this study done?
Data from CATCH were used for an analysis of RA disease activity and treatment escalation at 3, 6, 12, 24 and 60-month follow-ups. Patients were included if they had a diagnosis of RA as defined by the ACR 1987 or 2010 classification criteria for RA. For the analysis, patients were classified into remission, low disease activity, moderate disease activity and high disease activity using the DAS28 definitions. Treatment escalation was defined as any of the following: 1) increased dose of methotrexate; 2) addition of a new DMARD; 3) addition of a biologic; or 4) switching a biologic.

What were the results of the study?
2256 patients were included in the study.

At the start of the study:
• 90% of patients were on a DMARD and 49% were taking more than one DMARD;
• 58% of patients were on an NSAID;
• 46% of patients were on a steroid; and,
• 2.4% of patients were on a biologic.

Numbers of patients with moderate disease activity who received escalating therapy were as follows:
• 39% of patients or 204 of 519 patients at 3 months;
• 32% of patients or 139 of 434 patients at 6 months;
• 23% of patients or 82 of 363 patients at 12 months;
• 24% of patients or 59 of 241 patients at 24 months; and,
• 18% of patients or 12 of 65 patients at 60 months.

In patients with high disease activity, escalation of therapy was experienced by:
• 61% of patients or 136 of 223 patients at 3 months;
• 44% of patients or 69 of 156 patients at 6 months;
• 33% of patients or 30 of 90 patients at 12 months;
• 41% of patients or 24 of 59 patients at 24 months; and,
• 6% of patients or 1 of 16 patients at 60 months.

This shows that patients who had high disease activity received escalation in therapy more often than patients who had moderate disease activity at the same time point.

At 3 months, in patients with moderate or high disease activity who did not have an escalation of therapy, only 44% of them (or 179 of 399 patients) were on DMARD combination therapy. The percentage of erosions in this group increased to 11% of patients (or 130 of 1184 patients) at 24 months and 13% of patients (or 53/406) at 60 months.

The reasons why these patients with moderate to high disease activity did not receive an escalation of therapy require more investigation. These results could indicate that more effort is required to apply a treat to target approach.


No Sex Bias in the Escalation of Therapy in the Treatment of Early Inflammatory Arthritis

Stephanie Garner1, Cheryl Barnabe1, Gilles Boire2, Carol Hitchon3, Ed Keystone4, Boulos Haraoui5, Carter Thorne6, Diane Tin6, Shahin Jamal7, Janet Pope8, Vivian Bykerk91University of Calgary, Calgary; 2Université de Sherbrooke, Sherbrooke; 3University of Manitoba, Winnipeg; 4Mount Sinai Hospital, University of Toronto, Toronto; 5Institut de rhumatologie de Montreal, Montréal; 6Southlake Regional Health Centre, Newmarket; 7University of British Columbia, Vancouver; 8University of Western Ontario, St Joseph's Health Care, London; 9Hospital for Special Surgery, New York.

The study's goal was to see if the RA disease activity measurement and medication changes of women and men with early RA were influenced in any way by their sex. Rheumatologists used disease activity measures called the DAS28 and HUPI. HUPI stands for Hospital Universitario La Princesa Index and is a validated way to measure disease activity in early RA that corrects for sex bias. Patients were classified into different disease states based on the DAS28 and HUPI scores for remission, low disease activity and moderate/high disease activity. The researchers found that the proportion of patients on DMARDs and biologics did not differ by sex at any time and there were no sex differences in the escalation of medication. The HUPI scores correlated well with the DAS28, showing that the DAS28 does not bias for sex when measuring a person's RA disease activity.

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What was the purpose of the study?
Studies have shown that females with early inflammatory arthritis have higher disease activity and worse patient-reported outcomes. Despite this there are no sex differences in erosions, showing that even though males and females start at different disease states, in 5 years they end up at the same place disease-wise. It is thought that the current tools to measure disease activity are biased against females. The Hospital Universitario La Princesa Index (HUPI) is a validated tool in early RA that corrects for sex bias by adjusting for both the tender joint count and ESR for males and females. The study's goal was to see if the RA disease activity measurement and medication changes of women and men with early RA were influenced in any way by their sex. The researchers also wanted to validate the HUPI in a Canadian population of RA patients.

How was this study done?
Data from CATCH were used to analyze disease activity and treatment escalation at 3, 6, 12, 24 and 60- month follow-up for males and females. Patients were included if they were diagnosed with RA using the ACR 1997 or 2010 classification criteria and their sex was documented. Patients were classified into remission, low disease activity and moderate/high disease activity using the DAS28 and the HUPI measures.

What were the results of the study?
2228 patients (1619 females, 609 males) were in the study.

At the start of the study:
• Females were younger and more frequently seropositive;
• Males had more erosions and higher swollen joint count;
• The DAS28 was similar in both groups (5.1 and 5.0);
• The HUPI score was higher in males (8.9 in males versus 8.3 in females);
• More females were taking NSAIDs and steroids but by twelve months it was the same for men and women.

Throughout the study:
• The proportion of patients on DMARDs and biologics did not differ by sex at any time point;
• There were no sex differences in the increase of therapy when patients were broken out by disease state as measured by DAS28 or HUPI;
• More males were in remission at 60 months measured both by the DAS28 (67% of men and 52% of women) and HUPI (53% of men and 50% of women).
• There were no sex differences in erosions at follow-up.

Overall, the HUPI correlated well with the DAS28 and there were no sex differences in treatment or escalation of therapy.


Prevalence and Impact of Inflammatory Multimorbid Conditions on Trajectories of Disease Activity in the First Year of Follow-up in a Multi-Center ERA Cohort

Orit Schieir1, Susan J. Bartlett2, Carol Hitchon3, Janet E. Pope4, Gilles Boire5, Boulos Haraoui6, Edward C. Keystone7, Carter Thorne8, Diane Tin9 and Vivian P. Bykerk101McGill University, Montreal; 2Department of Medicine, Division of ClinEpi, Rheumatology, Respirology, McGill University, Montreal; 3University of Manitoba, Winnipeg; 4University of Western Ontario, St Joseph's Health Care, London; 5Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 6Institut de Rhumatologie de Montréal, Montreal; 7Mount Sinai Hospital, Toronto; 8University of Toronto and Southlake Regional Health Centre, Newmarket; 9The Arthritis Program, Southlake Regional Health Centre, Newmarket; 10Divison of Rheumatology, Hospital for Special Surgery, New York.

People with RA also often have other chronic conditions, which is called "multimorbidity". Higher numbers of other conditions are associated with decreased response to treatment and persistent disease activity in RA. However little is known about which specific conditions are related to differences in RA outcomes. This study was done to estimate the prevalence and impact of chronic inflammatory multimorbidity on RA disease activity in RA patients within their first year of diagnosis. The most prevalent other chronic conditions included: depressive symptoms, obesity, pulmonary disease, cardiovascular disease, and other rheumatic conditions, followed by diabetes and cancer. Bowel disease and psoriasis were least prevalent. Depressive symptoms were associated with higher initial RA disease activity and both depressive symptoms and obesity were associated with less positive change in disease activity with time. It is thought that treatment approaches to address multimorbid rather than one inflammatory condition may yield better outcomes related to all of these comorbid conditions.

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What was the purpose of the study?

Patients with rheumatoid arthritis also often have other chronic conditions, which is called “multimorbidity”. Higher numbers of other conditions are related to decreased response to RA treatment and persistent RA disease activity. However little is known about which conditions have stronger associations with RA outcomes. This study was done to estimate the prevalence and impact of chronic inflammatory multimorbidity on RA disease activity in RA patients within their first year of diagnosis.

How was this study done?

CATCH participants were enrolled in this study if they completed a standardized clinical assessment and self-report questionnaire every 3-months in the first year of diagnosis, who met 1987 or 2010 ACR/EULAR RA criteria, and had at least two disease activity measures (DAS28) in the first year. Patients reported information on chronic inflammatory conditions diagnosed by a doctor including cardiovascular disease, pulmonary disease, bowel disease, diabetes, cancer, obesity, psoriasis, and information was collected on depressive symptoms from SF-12 responses. Prevalence of each condition as well as chronic inflammatory multimorbidity counts were estimated. Models were used to examine individual and additive effects of each chronic inflammatory condition on DAS28 disease activity over time in the first year.

What were the results of the study?

There were 1595 patients in the study. Multimorbid inflammatory conditions were common with 72% of patients having at least 1 condition, 34% of patients having at least 2 conditions, and 10% of patients having 3 or more conditions. Most prevalent chronic conditions were: depressive symptoms in 40% of patients, obesity in 32% of patients, pulmonary disease in 14% of patients, cardiovascular disease in 12% of patients and other rheumatic conditions in 12% of patients. Diabetes affected 8% of patients and 7% of patients also had cancer. The least prevalent conditions were bowel disease in 4% of patients and psoriasis in 4% of patients. Depressive symptoms were associated with higher starting disease activity and both depressive symptoms and obesity were associated with less change in DAS28 over time (indicating less improvement in RA disease activity over time).

Results of the present study showed that multimorbidity with other chronic inflammatory conditions is common in early RA patients. Integrated treatment approaches to address multimorbid rather than single inflammatory conditions may yield better outcomes.


Self-Management of RA Flares Varies by Severity and Duration: Results from CATCH

Susan Bartlett1, Clifton Bingham2, Orit Schieir3, Kathleen Andersen4, Daming Lin5, Gilles Boire6, Boulos Haraoui7, Carol Hitchon8, Shahin Jamal9, Ed Keystone10, Janet Pope11, Diane Tin12, Carter Thorne12, Vivian Bykerk4. 1McGill University, Montreal; 2Johns Hopkins, Baltimore; 3McGill University, Montreal; 4Hospital for Special Surgery, New York; 5Mount Sinai Hospital, Toronto; 6Université de Sherbrooke, Sherbrooke; 7Institut de Rhumatologie de Montréal, Montreal; 8University of Manitoba, Winnipeg; 9University of British Columbia, Vancouver; 10Mount Sinai Hospital, University of Toronto, Toronto; 11University of Western Ontario, St Joseph's Health Care, London; 12Southlake Regional Health Centre, Newmarket.

We looked at patient reports of flare with respect to both RA disease activity and how people self-manage these flares. At each visit to their rheumatologist, patients provided ratings of how bad their flare was, how long the flare lasted, symptoms of their flare, how the flare impacted their ability to function and any self-management they undertake. Patient reports of RA flare are supported by patient and clinical measures of higher disease activity at the same time they report their flare. Self-management is common and increases with flares being bad and lasting for a long time. Self-management includes decreasing a person's participation in activities, using more medications, and trying to reduce symptoms to minimize how flares impact a person. Self-management is usually started early into flares and highlights how flares can have a huge impact on a person's quality of life.

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What was the purpose of the study?
Early rheumatoid arthritis (ERA) patients often report being in a disease flare at their rheumatology appointments. We evaluated patient reports of flare with respect to disease activity and self-management behaviors (SM) in CATCH.

How was this study done?
At each rheumatology appointment, patients provided ratings of how bad their flare was, its length, symptoms, how the flare affected their ability to function, and any type of self-management they tried. Joint counts were recorded and CDAI scores were calculated. A checklist of self-management strategies was developed based on international studies by the OMERACT RA Flare Group.

What were the results of the study?
In total, 1983 patients were in the study. The 24% of patients who reported being in flare were mostly female (76%), Caucasian (78%) and educated (53% had more than a high school education), with an average age of 53 years and symptoms for just over 3 years. On a scale of 1-10 (with 10 being the worst), the average flare severity was 5.4, and 67% of patients in a flare reported that their flare had lasted more than a week. Patients who reported a flare also had significantly higher levels of pain, fatigue, stiffness, disability, reduced participation, and difficulty coping.

Self-management attempts did not differ between men and women and included:
• 50% of patients using analgesics;
• 13% of patients using steroids;
• 45% of patients reducing activities;
• 28% of patients avoiding activities;
• 17% of patients calling their rheumatologist for help;
• Some patients trying massage, heat/cold, or exercise.

Overall, self-management increased with flare severity for all activities except selected behaviors and steroid use, and trends were seen based on length of flare and use of analgesics, avoiding activities, and calling the rheumatologist. Patients within one year of diagnosis were significantly more likely to report using self-management compared to those patients who have lived with a diagnosis of RA for more than one year (79% of newly diagnosed patients versus 66% of other patients) mostly using massage, heat and exercise. More patients on biologics reduced activities (60% of patients compared to 43% of patients) or avoided activities (44% of patients compared to 25% of patients) compared to patients who are not on biologics.

For patients with flare severity of greater than or equal to 4 and who had flares lasting more than one week, 80% of patients reported self-management behaviours including:
• 57% used analgesics;
• 46% reduced activities;
• 40% tried massage, heat/cold or exercise;
• 34% avoided activities; and,
• 19% called their physician for help.

Patient reports of RA flare are reliably associated with patient and clinical indicators of higher disease activity at the same time that they report their flare. Self-management is common and increases with how bad and how long a flare lasts. Self-management includes limiting participation in activities and using additional medications and behaviors to reduce symptoms and the overall impact of flares. Self-management appears to be started early into flares which shows their substantial impact on a person's quality of life.


Smoking and Excess Weight Attenuate Rate of Improvement over First 3 Years in Early RA

Susan J. Bartlett1,2, Orit Schieir3, Kathleen Andersen4, Gilles Boire5, Boulos Haraoui6, Carol Hitchon7, Edward Keystone8, Janet E. Pope9, J Carter Thorne10, Diane Tin11, Vivian P. Bykerk12 and Canadian Early Arthritis Cohort (CATCH) Investigators. 1Department of Medicine, Division of ClinEpi, Rheumatology, Respirology, McGill University, Montreal; 2Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore; 3University of Toronto, Toronto; 4Rheumatology, Hospital for Special Surgery, New York; 5Rheumatology Division, CHUS - Sherbrooke University, Sherbrooke; 6Institut de Recherche en Rhumatologie de Montréal (IRRM), Montreal; 7University of Manitoba, Winnipeg, MB; 8Mt. Sinai Hospital, University of Toronto, Toronto; 9University of Western Ontario, St Joseph's Health Care, London; 10Southlake Regional Health Centre, Newmarket; 11The Arthritis Program, Southlake Regional Health Centre, Newmarket; 12Divison of Rheumatology, Hospital for Special Surgery, New York.

Early and aggressive treatment of RA with the aim to reach remission is the goal, and is related to patients doing better in the long run. We have shown before that people with RA who smoke and have excess weight are less likely to achieve sustained remission in the first 3 years after diagnosis. Smoking and extra weight are variables that affect RA that a person is able to control – they are called modifiable factors. This study showed that sex, excess weight and smoking had a significant negative affect on rates of RA disease activity improvement over the first 3 years. Improvement in RA in people who quit smoking was similar to those who had never smoked, showing that quitting smoking had a very positive affect on RA disease activity. The results show how a person's lifestyle may impact how their treatment works and that there may be value in helping people stop smoking and lose weight to help them do better with their RA.

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What was the purpose of the study?

Early, aggressive treatment to achieve remission is the goal when treating early RA, and is related to better long-term outcomes. We have previously shown that people who smoke and have excess weight are less likely to achieve sustained remission in the first 3 years. Smoke and weight are factors that a person can have some control over and are called modifiable. In this study we looked at how smoking, excess weight, and sex affect rate of disease activity improvement measured with the DAS28 in the first 3 years of early RA.

How was this study done?

Participants in CATCH had to meet the following criteria to be included in the study: 1987 or 2010 ACR criteria for RA, RA symptoms for less than 1 year, DAS28 of equal to or greater than 2.6, and information on body mass index (also called BMI) and DAS28 at the study start and at least 1 follow up visit. Patients were followed every 3 months in year 1, every 6 months in year 2, and annually after that. We examined how sex, excess weight (defined by BMI as being overweight or obese) and smoking (defined as currently smoking, a former smoker, or never smoked) impacted DAS28 at the study start and over time. We also looked at age, race, education, comorbidities, symptom duration, and treatment at the study start.

What were the results of the study?

There were 1109 participants in the study with an average age of 54 years with symptoms for 6 months, and most were female (72%) and white (81%). Among men in the study, 44% were overweight, 35% were obese and 22% smoked.  Among women in the study, 31% were overweight, 32% were obese and 15% smoked. At the study start, 73% of participants were on methotrexate.

The average disease activity (measured by DAS28) at the study start was moderate to high and dropped significantly at each visit. Sex, excess weight, and smoking were not significantly associated with disease activity at the start of the study. However, each of these factors (sex, excess weight and smoking) added to the rate of disease activity change over time. At each time point, the average rate of improvement in RA disease activity was:

  • lower in women versus men,
  • lower in those who were overweight and obese versus those with a healthy weight, and,
  • lower for current smokers versus non-smokers.

Former smokers who were no longer smoking did not see significant changes in their disease activity because of their previous smoking (that means that quitting smoking had a positive effect on their disease activity).

Our results showed that sex, excess weight and smoking significantly decreased the rates of improvement in RA disease activity over the first 3 years. Improvement in disease activity among former smokers was similar to those who had never smoked. These results help show how lifestyle may impact treatment outcomes and the potential importance of referring people with RA to programs that will help them stop smoking and lose weight. Unlike some other factors that contribute to RA, smoking and weight may be controlled by a person and represent factors within their own control that can impact their RA outcomes.


The 28-Joint Disease Activity Score (DAS28) Using C-Reactive Protein Yields Lower Thresholds Compared To Conventional DAS28 With Erythrocyte Sedimentation Rate In Early Rheumatoid Arthritis

B. Kuriya1, O. Schieir2, D. Lin1, J. Pope3, G. Boire4, B. Haraoui5, C. Thorne6, D. Tin6, C. Hitchon7, E. Keystone1, V. Bykerk8 and CATCH Investigators.

1Medicine, Mount Sinai Hospital, University of Toronto; 2Dalla Lana School of Public Health, University of Toronto, Toronto; 3Medicine, St. Josephs Health Care, University of Western Ontario, London; 4Medicine, Universite de Sherbrooke, Sherbrooke; 5Medicine, Institut de Rhumatologie, Montreal; 6Medicine, Southlake Regional Health Centre, Newmarket; 7Medicine, University of Manitoba, Winnipeg; 8Medicine, Hospital for Special Surgery, New York.

Rheumatologists measure patients' RA disease activity using a tool called the Disease Activity Score (DAS28). The DAS28 can be calculated using measures of a patient's C-reactive protein (CRP) or erythrocyte sedimentation rate (DAS28-ESR), and the researchers wanted to see if using these two different values to calculate the DAS28 provided the same score or not. There were 995 patients in the study. The researchers found that the DAS28 calculated using either a patient's CRP or ESR values provided the same DAS28 score.

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What was the purpose of the study?
Rheumatologists measure patients' RA disease activity using a tool called the Disease Activity Score (DAS28). The DAS28 is a number that can be calculated using measures of a patient's C-reactive protein (CRP) or erythrocyte sedimentation rate (DAS28-ESR). The researchers wanted to see if using these two different values to calculate the DAS28 provided the same score or not.

How was this study done?
The researchers looked at patients' data at the start of the study and at one year. Patients needed to have complete information to calculate the DAS28 with both CRP and ESR measures. A number of statistical methods were used to make sure that the DAS28 scores calculated using either CRP or ESR were the same or not.

What were the results of the study?
There were 995 early RA patients in the study. Though DAS28 scores calculated using CRP (also called DAS28-CRP) and ESR (called DAS28-ESR) were highly correlated, DAS28-ESR scores were higher than DAS28-CRP scores no matter a patient's disease activity. Differences between DAS28-CRP and DAS28-ESR were greater at lower ranges of the DAS28 and were most different in women and older patients. This suggests that using ESR or CRP to calculate the DAS28 is a reasonable for research purposes. Overall there was moderate to good agreement between newly calculated DAS28-CRP and DAS28-ESR.


Treatment Response to Conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) and Biologics in Seropositive and Seronegative Patients with Early Rheumatoid Arthritis: Results from CATCH (Canadian Early Arthritis Cohort)

B. Aberumand*1, V. Bykerk2, O. Schieir3, D. Lin2, G. Boire4, B. Haraoui5, C. A. Hitchon6, C. Thorne7, D. Tin7, E. C. Keystone2, S. Jamal8, J. E. Pope1

1Medicine, Schulich School of Medicine and Dentistry, London; 2Mount Sinai Hospital, Toronto; 3University of Toronto Dalla Lana School of Public Health, Toronto; 4Medicine, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke; 5Medicine, University of Montreal Hospital Research Centre (CRCHUM), Montreal, 6Medicine, University of Manitoba, Winnipeg; 7Southlake Regional Health Centre, Newmarket; 8University of British Columbia, Vancouver.

The CATCH researchers wanted to see if patients with early rheumatoid arthritis who were seropositive versus seronegative for rheumatoid factor and/or anti-citrullinated protein antibodies (ACPA) responded differently to disease-modifying anti-rheumatic drugs (DMARDs). A total of 867 patients were seropositive and 201 were seronegative (759 were RF positive 759, 385 were RF negative, 539 were ACPA positive, and 349 were ACPA negative 349). The researchers found:

  • At 3 months, patients who were RF positive and combined seropositive (that is, both positive for RF and ACPA) had better response to methotrexate used in combination with other DMARDs than the seronegative patients, but not patients who were ACPA positive versus ACPA negative;
  • At 6 months, patients on methotrexate used in combination with other DMARDs who were RF positive versus RF negative and patients who were seropositive that is, positive for RF and ACPA) versus seronegative (negative for both RF and ACPA) responded better to treatment.

In early RA, RF and ACPA status affected treatment response to methotrexate combination therapy, with better changes in disease activity at 3 and 6-months in seropositive compared with seronegative patients. These findings may help physicians and patients make decisions on treatment based on a patient's RF and ACPA status in the future.

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What was the purpose of the study?

Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) status may affect treatment response in early rheumatoid arthritis (ERA). The researchers wanted to see if they could find differences in how patients responded to disease modifying anti-rheumatic drugs (DMARDs) and biologics in seropositive versus seronegative patients for RF and/or ACPA.

How was this study done?

Researchers examined records of patients in CATCH who were diagnosed with RA, had symptoms for less than one year, were not in remission at the start of the study and had RF or ACPA data available, disease activity scores (DAS28) at the study start and follow-up. Treatment with methotrexate alone, methotrexate combination therapy (defined as methotrexate plus one or more DMARD), biologic therapy and other therapy on change in DAS28 at 3 and 6 month follow up in patients who were seropositive (positive for RF and/or positive for ACPA) and seronegative (negative for RF and ACPA), patients who were RF positive and RF negative, and patients who were ACPA positive and ACPA negative, respectively.

What were the results of the study?

1068 patients were in the study, and a total of 867 (81%) patients were seropositive and 201 (19%) were seronegative (66% were RF positive, 34% were RF negative, 61% were ACPA positive, and 39% were ACPA negative). The researchers found that:

  • At 3 months, better treatment response to methotrexate used with other DMARDS was seen in patients who were RF positive versus RF negative as well as the combined seropositive (RF positive and ACPA positive) versus patients who were ACPA positive versus ACPA negative;
  • At 6 months, better response to methotrexate used with other DMARDs was seen in patients who were RF positive versus those who were RF negative, and those that were seropositive (RF positive and ACPA positive) versus seronegative (RF negative and ACPA negative)
  • No other patterns in terms of response to other treatments based on antibody status could be determined.

In patients within 6 months of their RA diagnosis, RF and ACPA status affected treatment response to methotrexate used with other DMARDs, with more positive change in disease activity at 3- and 6-months in seropositive compared with seronegative patients. The findings might help lead to ways to predict who will best respond to treatments based on their RF and ACPA status in the future.