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.


Additions to Methotrexate with Conventional and Biologic DMARDs in Rheumatoid Arthritis: Are There Differences in Subsequent Time to Treatment Failure?

Sasha Bernatsky1, Orit Schieir2, Cristiano S. Moura3, Marie-France Valois2, Susan J. Bartlett2, Carol A Hitchon4, Janet E. Pope5, Gilles Boire6, Boulos Haraoui7, Edward C Keystone8, Diane Tin9, Carter Thorne8, Vivian P. Bykerk10 and the Canadian early ArthriTis CoHort (CATCH) Investigators.

1Research Institute of the McGill University Health Centre; 2McGill University; 3McGill University Health Centre; 4University of Manitoba; 5University of Western Ontario, St Joseph's Health Care; 6Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke; 7Institut de Rhumatologie de Montréal; 8University of Toronto; 9Southlake Regional Health Centre; 10Mt Sinai Hospital.

The researchers compared approaches to RA treatment of conventional DMARDs and biologic DMARDs after an initial treatment with methotrexate was determined to not be working for the patient or had resulted in a severe adverse event. Methotrexate is one of the common DMARDs that people diagnosed with RA will take as a first medication, and here the researchers compared all medication use to patients who started by taking methotrexate by pill only first. The researchers found that for patients who start on methotrexate but must change to other medications, those people who next take biologics or triple therapy remain on that treatment longer without further changes to their medications.

Read more

What was the purpose of the study?

The researchers compared approaches to RA treatment of conventional DMARDs and biologic DMARDs after an initial treatment with methotrexate was determined to not be working for the patient or had resulted in a severe adverse event.

How was this study done?

Patients from CATCH were part of the study if they were within one year of their RA symptoms’ start and started methotrexate (with or without other DMARDs) within 90 days of entering the CATCH study and changed therapy somehow (for example, maybe they changed if they took methotrexate by pill or injection, lowered or stopped methotrexate or other DMARD, or added another DMARD or biologic). The time that the patient made a medication change was considered time zero. Patients were followed from time zero to look at stopping or adding to their therapy. All results were compared to patients who were only taking methotrexate pills.

What were the results of the study?

There were 911 patients from the CATCH study who were part of this project. At time zero, the most common second treatments were methotrexate and another DMARD (in 33% of patients) and non-methotrexate DMARDs (in 26% of patients). RA patients who took biologics and/or used triple therapy took those treatments longer before they needed to change medications than the patients who were taking only methotrexate by pill. 


Does Guideline-Based Care Improve Outcomes That Matter to Patients? Tighter Control, Less Suffering, and Greater Well-Being over the Past Decade in Canadian RA Patients

Susan J. Bartlett1,2, Orit Schieir3, Marie-France Valois1, Carol A Hitchon4, Janet E. Pope5, Gilles Boire6, Boulos Haraoui7, Edward C. Keystone3, Diane Tin8, Carter Thorne3, Vivian P. Bykerk9 and The Canadian early ArthriTis CoHort (CATCH) Investigators.

1McGill University; 2Johns Hopkins University School of Medicine; 3University of Toronto; 4University of Manitoba; 5University of Western Ontario, St. Joseph's Health Care; 6Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke; 7Institute de Rheumatologie; 8Southlake Regional Health Centre; 9Mt Sinai Hospital.

Recommendations for the best practice of treatment of people with RA are published in scientific journals and presented at conferences by medical professionals and associations. These recommendations are used by healthcare providers to ensure they use the most up to date methods and approaches to RA treatment, and are updated over time as more is learned about treatments and patient outcomes. These recommendations, including some called the 2011 Canadian RA Treatment Recommendations and Treat to Target, may improve the quality of care and outcomes for people with RA, however the impact of recommendations on outcomes that matter most to patients (these are also called patient reported outcomes or PROs) has not been formally evaluated. The CATCH researchers compared changes in patient reported outcomes in the first year of follow up, as well as before (2007-10) and after (2011-16) the release of the 2011 Canadian RA Treatment Recommendations. The study results suggest that better control of RA in the first year of diagnosis meant improvements in pain, fatigue and disability, which are symptoms that patients identify as important. With improvements in these symptoms, patients reported greater overall well-being. These findings provide evidence to support the importance of early identification and control of RA activity to improve long-term outcomes and quality of life in people with RA.

Read more

What was the purpose of the study?

Recommendations for the best practice of treatment of people with RA are published in scientific journals and presented at conferences by medical professionals and associations. These recommendations are used by healthcare providers to ensure they use the most up to date methods and approaches to RA treatment, and are updated over time as more is learned about treatments and patient outcomes. These recommendations, including some called the 2011 Canadian RA Treatment Recommendations and Treat to Target, may increase quality of care and improve outcomes for people with RA, however the impact of recommendations on outcomes that matter most to patients (these are also called patient reported outcomes or PROs) has not been formally evaluated. The CATCH researchers compared changes in patient reported outcomes in the first year of follow up, as well as before (2007-10) and after (2011-16) the release of the 2011 Canadian RA Treatment Recommendations.

How was this study done?

Early RA patients were in the study who were part of the CATCH study between 2007-2016 and who were diagnosed because they met the 1987 or 2010 criteria for diagnosing RA and had active RA at the study start. These patients had standardized rheumatology visits that included clinical assessments, questionnaires that they answered, and laboratory tests every 3 months. Treatment of patients was up to their rheumatologist and CATCH researchers met every year to discuss ways to help their patients improve their RA outcomes. The researchers looked at changes in a number of clinical measurements including DAS28, pain, fatigue, patient global and HAQ at 6 and 12 months before and after the recommendation guidelines were released.

What were the results of the study?

The study included 1,942 people with RA, and 72% were women and were 55 years old on average, had 2 comorbidities, and had RA symptoms for 6 months. At the study start, 95% of patients had moderate or high RA activity as measured by the DAS28 (42% of patients had moderate disease activity and 53% had high disease activity) and 92% of patients were treated at the study start with non-biologic DMARDs and 75% with methotrexate. As average DAS28 scores decreased over the first year (showing that RA activity decreased with time) improvements were seen in patient reported outcomes (that is, measures that are important to patients), including patient global, pain, and fatigue. When comparing changes in patient reported outcomes in 2007-2010 against 2011-2016, there were more rapid improvements in patient global and pain at 6 and 12 months and similar improvements in HAQ and fatigue. This means that in 2011-2016, improvements in pain and overall patient well-being were seen, while only similar changes were seen in HAQ and fatigue.

The study results suggest that better control of RA in the first year of diagnosis meant improvements in pain, fatigue and disability, which are symptoms that patients identify as important. With improvements in these symptoms, patients reported greater overall well-being. These findings provide evidence to support the importance of early identification and control of RA activity to improve long-term outcomes and quality of life in people with RA.


Incidence of Infections in Early Arthritis

Meriem Kerbachi1, Louis Bessette2, Cristiano S. Moura3, Sasha Bernatsky4, Orit Schieir1, Susan J. Bartlett1, Carol Hitchon5, Janet E. Pope6, Gilles Boire7, Boulos Haraoui8, Edward C. Keystone9, Diane Tin10, Carter Thorne9, Vivian P. Bykerk11 and The Canadian early ArthriTis CoHort Study (CATCH) Investigators, 

1McGill University, 2Centre d'ostéoporose et de rhumatologie de Québec (CORQ); 3McGill University Health Centre; 4Research Institute of the McGill University Health Centre; 5University of Manitoba; 6University of Western Ontario, St. Joseph's Health Care; 7Centre Hospitalier Universitaire de Sherbrooke and Université de Sherbrooke; 8Institut de Rhumatologie de Montréal; 9University of Toronto; 10Southlake Regional Health Centre; 11Mt Sinai Hospital.

Only a few studies have looked at infection risk in people recently diagnosed with RA. This study’s goal was to estimate the incidence of infections in patients with early RA, focusing on the CATCH cohort of RA patients who were enrolled within 12 months of the start of their RA symptoms. A total of 1,728 RA patients were part of the research project and were followed for about 3 years. There were 452 infections in these patients and over 25% of these infections involved patients having to spend time in the hospital. Of the infections, 18% were pneumonia and half of the patients who had pneumonia had to spend time in the hospital. The study showed that there were many infections in people in this early RA cohort and a number of the infections included the need to stay in the hospital. 

Read more

What was the purpose of the study?

Only a few studies have looked at infection risk in people recently diagnosed with RA.  This study’s goal was to estimate the incidence of infections in patients with early RA, focusing on the CATCH cohort of RA patients who were enrolled within 12 months of the start of their RA symptoms.

How was this study done?

All patients with early RA enrolled in CATCH were part of this research study. Infections were reported by patients yearly to the CATCH cohort. From January 2007 to November 2015, the total number of infections was used to calculate incidence rates of infections.

What were the results of the study?

A total of 1,728 RA patients were part of the research project and were followed for 3 years on average. The participants were an average of 54 years old, 82% were Caucasian and 72% were women. Participants experienced symptoms for about 6 months before starting CATCH and had an average: Disease Activity Score 28 or DAS28 of 5.1 (which means their RA was very active), Simplified Disease Activity Index or SDAI of 28.6, and Clinical Disease Activity Index or CDAI of 27.1. One third of patients were on steroids at the study start and 91% were taking disease modifying anti-rheumatic drugs or DMARDs, with 73% having taken methotrexate, while less than 3% of patients had taken a biologic.

There were a total of 452 infections and over 25% of these infections involved patients having to spend time in the hospital. Of the infections, 18% were pneumonia and half of the patients who had pneumonia had to spend time in the hospital. The study showed that there were many infections in people in this early RA cohort and a number of the infections included the need to stay in the hospital.


Initial Use of Subcutaneous Methotrexate in Early Rheumatoid Arthritis is Associated with Decreased Time to Biologic Use: Results from the CATCH Cohort

Stephanie Gottheil1, Carter Thorne2, Orit Schieir3, Glen Hazlewood4, Gilles Boire5, Diane Tin2, Carol Hitchon6, Cheryl Barnabe4, Edward Keystone7, Susan Bartlett8, Boulos Haraoui9, Vivian Bykerk10, Janet Pope1, Canadian Early Arthritis Cohort (CATCH) Investigators

1Western University, London; 2Southlake Regional Health Centre, Newmarket; 3University of Toronto, Toronto; 4University of Calgary, Calgary; 5Université de Sherbrooke, Sherbrooke; 6University of Manitoba, Winnipeg; 7Mount Sinai Hospital, University of Toronto, Toronto; 8McGill University, Montreal; 9Institut de Rhumatologie de Montreal, Montréal; 10Hospital for Special Surgery, New York.

Treatment for moderate to severe early RA often involves taking methotrexate and aiming for remission. Optimizing methotrexate therapy may reduce the need for going on to a biologic. This study compared effects of different initial methotrexate-based treatment approaches (that is methotrexate alone – called monotherapy, in combination with other medications, and by pill or injection) to the time to when patients with early RA started to use a biologic.

Read more

What was the purpose of the study?

Treatment for moderate to severe early RA often involves taking methotrexate and aiming for remission. Optimizing methotrexate therapy may reduce the need for going on to a biologic. This study compared effects of different initial methotrexate-based treatment approaches (that is methotrexate alone – called monotherapy, in combination with other medications, and by pill or injection) to the time to when patients with early RA started to use a biologic.

How was this study done?

Participants were included in the study if they had RA (based on the 1987 or 2010 ACR/EULAR criteria), had symptoms for less than one year and had moderate or high disease activity (measured by the DAS28) at the study start, and were taking methotrexate. Patients who had taken a biologic were not included in the study. Patients were followed through the study until they started a biologic, left the study, or until the end of the 3-year period of the study.  The researchers looked at methotrexate-based treatment approaches (that is methotrexate alone – called monotherapy, in combination with other medications, and by pill or injection) to the time to when patients with early RA started to use a biologic.

What were the results of the study?

1189 participants were in the study, and 207 of them started to use a biologic during the 3-year study. The average time until patients started to take a biologic was 9 months. At the start of the study, 40% of patients were on methotrexate only (half took pills and have took methotrexate via injection) and 60% of patients took some form of methotrexate combination therapy. Combinations of medications included methotrexate and hydroxychloroquine; methotrexate, hydroxychloroquine, and sulfazaline; or other combinations.

There were no overall differences between methotrexate monotherapy and methotrexate combination therapy. However, patients who started on injected methotrexate only compared to patients who took it as a pill, saw a delayed time until they started a biologic. It is thought that injected methotrexate may be more effective compared to a pill version. Methotrexate combination therapy was not associated with longer time to biologic start, potentially due to provincial regulations requiring patients to try a combination DMARD therapy before initiating biologics. This study suggests that early use of injected methotrexate may delay the need for taking a biologic.


Large Tender Joints have the Greatest Impact on Longitudinal Trajectories of Function in Early Rheumatoid Arthritis

S. H. L. Lim1, O. Schieir2, S. Bartlett3, G. Boire4, B. Haraoui5, E. Keystone2, D. Tin6, C. Thorne6, J. Pope7, V. Bykerk8, C. Hitchon1  on behalf of Canadian Early Arthritis Cohort Canada (CATCH) Investigators.

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

Because people with early rheumatoid arthritis (ERA) whose disease is under control still have many issues with their physical function, factors that affect function need to be studied. Large weight bearing joints are more likely to impact overall function than small non-weight bearing joints although how much of an impact this makes may be dependent on the type of task. The researchers found that using different ways to measure large and small joints both affected the health assessment questionnaire (HAQ) score over time. Overall, tender joints had a greater impact on function than swollen joints and large tender joints had the most impact on function.

Read more

What was the purpose of the study?

Because people with early rheumatoid arthritis (ERA) whose disease is under control still have many issues with their physical function, factors that affect function need to be studied. Large weight bearing joints are more likely to impact overall function than small non-weight bearing joints although how much of an impact this makes may be dependent on the type of task. A measurement scale for physical function called the Lansbury Articular Index (LAI) weights large joints more than small joints and it is thought that the LAI may have stronger associations with function than standard joint counts that give equal weight to small and large joints.

This study had two goals:

  1. To compare the relationship of weighted and non-weighted arthritis joint measures with physical function over time; and
  2. To determine the impact of large compared to small joint involvement on the health assessment questionnaire over time (also called the HAQ trajectory).

How was this study done?

ERA participants had symptoms for less than one year when they were enrolled in a study and were followed over time. Arthritis activity measures (disease activity score (DAS28), tender 28 joint count (TJC28), swollen 28 joint count (SJC28), function (Health Assessment Questionnaire; HAQ) were recorded at each rheumatology visit. The LAI weighted 28 joint count (LT28) and swollen joint count (LS28) were calculated based on the standard 28 joint sites. Relationships of how these measures changed over time were determined. 

What were the results of the study?

There were 2,125 study participants: 73% were female, were on average 53 years old, had average disease activity score (DAS28) of 5.1, and were followed for 2 years. At their last visit, 44% of participants were in remission (which meant that they had a DAS28 of less than 2.6). The HAQ score over time was highly correlated with the DAS28, LT28, and TJC28. The HAQ score over time was moderately correlated with the LS28 and SJC28. Each increase in joint involvement was associated with an increase in HAQ. Large joints had greater effects on HAQ than small hand joints.

Both the Lansbury and standard joint count correlate with HAQ over time in ERA. The weighting of large joints in LAI did not fully show the impact of large joint involvement in ERA probably because HAQ questions emphasize large joint activities. The effects of large joint swelling may be under recognized because it is hard to measure hip, shoulder or elbow swelling. Overall, tender joints had a greater impact on function than swollen joints and large tender joints had the most impact on function.


Methotrexate Treatment Strategies in an Early Rheumatoid Arthritis Cohort

Sasha Bernatsky1, Orit Schieir2, Cristiano S. Moura3, Marie-France Valois4, Susan J. Bartlett5, Carol A Hitchon6, Janet E. Pope7, Gilles Boire8, Boulos Haraoui9, Edward C Keystone10, Diane Tin11, Carter Thorne2, Vivian P. Bykerk12 and The Canadian early ArthriTis CoHort (CATCH) Investigators.

1Research Institute of the McGill University Health Centre; 2University of Toronto; 3McGill University Health Centre, 4McGill University; 5Johns Hopkins University School of Medicine; 6University of Manitoba; 7University of Western Ontario, St Joseph's Health Care; 8Centre Hospitalier Universitaire de Sherbrooke and Université de Sherbrooke; 9Institute de Rheumatologie; 10Mount Sinai Hospital; 11Southlake Regional Health Centre; and 12Mt Sinai Hospital.

Methotrexate is often recommended as a first medication to treat people with early RA, but how it is prescribed may range widely. This study looked at how methotrexate was taken in an early RA cohort, from start of methotrexate treatment and looking at time before patients had to change medications. The study looked at the time a person was on their starting methotrexate-based treatment until they needed to make a medication change because it was no longer working or because they had a serious adverse effect. Overall, 61% of patients had to make a medication change because the medication stopped working as a treatment for their RA. All other treatments that included methotrexate in some type of combination worked longer in patients compared to those who took methotrexate pills only. 

Read more

What was the purpose of the study?

Methotrexate is recommended as a first medication to treat people with early RA, but how it is prescribed may range widely. This study looked at how methotrexate was taken in an early RA cohort, from start of methotrexate treatment and looking at time before patients had to change medications.

How was this study done?

Participants from the CATCH study were part of the research project who were within one year of the start of their RA symptoms and diagnosed with RA based on the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) RA criteria. These participants started methotrexate (with or without other disease modifying anti-rheumatic drugs - also called DMARDs) within 90 days of being enrolled in CATCH. The study looked at the time a person was on their starting methotrexate-based treatment until they needed to make a medication change because it was no longer working or because they had a serious adverse effect. A medication changed was defined as including a change from pill to injection of methotrexate or vice versa, adding or stopping a DMARD and/or a biologic, and changing dose or frequency of a DMARD or biologic.

What were the results of the study?

The researchers studied 1,484 early RA patients, with most of these patients starting either on methotrexate alone as a pill or via injection or methotrexate plus another drug. At the study start, patients were an average of 54 years old, had symptoms for 5 months, their average DAS28 scores were 5.3 (meaning that their RA was very active), and 38% were taking oral steroids. Overall, 61% of participants had to make a medication change because the medication stopped working as a treatment for their RA.

All other treatment approaches that included methotrexate in some type of combination worked longer in patients compared to those who took methotrexate pills only. 


Multimorbid Conditions Linked with Inflammation are Prevalent Around the Time of RA Diagnosis and Associated with Disease Activity in the First Year of Follow Up: Results from the Canadian Early Arthritis Cohort

Orit Schieir1, Susan Bartlett2, Carol Hitchon3, Janet Pope4, Gilles Boire5, Boulos Haraoui6, Edward Keystone7, Carter Thorne8, Diane Tin8, Vivian Bykerk9, Canadian Early Arthritis Cohort (CATCH) Investigators.

1University of Toronto, Toronto; 2McGill University, Montreal, 3University of Manitoba, Winnipeg, 4Western University, London, 5Université de Sherbrooke, Sherbrooke Beaconsfield; 6Institut de Rhumatologie de Montreal, Montréal; 7Mount Sinai Hospital, University of Toronto, 8Southlake Regional Health Centre, Newmarket; 9Hospital for Special Surgery, New York.

At diagnosis of RA, the researchers wanted to estimate the prevalence of 9 conditions linked with inflammation. The researchers also wanted to determine these conditions’ associations with RA disease characteristics, approaches to treatment, and the course of disease activity in the first year after diagnosis. People with early RA often have other conditions that are linked to inflammation. These other conditions may be associated with early disease presentation, treatment, and worse RA activity over time. More studies are needed to determine if treatment for more than one condition rather than just one inflammatory condition may provide better outcomes for people with early RA.

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What was the purpose of the study?

At RA diagnosis, the researchers set out to estimate the prevalence of 9 conditions previously linked with inflammation. The researchers also wanted to determine these conditions’ associations with RA disease characteristics, approaches to treatment, and the course of disease activity in the first year after diagnosis.

How was this study done?

Data from participants in the CATCH study were analyzed. Participants needed to be diagnosed with RA (based on the 1987 or 2010 ACR/EULAR RA criteria) and have at least two disease activity score (DAS28) measures available in the first year. The researchers looked at whether or not participants also had the following other conditions at the study start:

  1. cardiovascular disease (CVD),
  2. diabetes,
  3. cancer,
  4. pulmonary disease,
  5. bowel disease,
  6. other rheumatic diseases,
  7. psoriasis,
  8. obesity (as measured by the body mass index, also called BMI) and
  9. depressive symptoms.

The conditions listed in 1-7 were all obtained from patients self-reporting that a doctor had diagnosed them with the condition. The researchers also looked at age, sex, race, education, smoking, symptom duration and RA treatment, and compared clinical characteristics in RA and each condition against only RA.

What were the results of the study?

1595 participants were in the study. At the study start, 92% of participants were treated with disease modifying anti-rheumatic drugs (also called DMARDs) (76% were taking methotrexate and 2% were taking a biologic). Over 70% of early RA patients had at least one other condition, and 33% reported multiple conditions. Patients with multiple conditions were often older and had more severe RA at the study start. Compared to patients who had RA only, patients with RA and cardiovascular disease and patients RA and depressive symptoms were much more likely to be using steroids at the study start. Patients who had RA and diabetes, other rheumatic diseases and depressive symptoms, also had higher RA disease activity at the study start (measured by DAS28), and their RA did not improve as much over time. People with RA and pulmonary disease, bowel disease, psoriasis and obesity were associated had less improvement of their RA disease activity over time, and people with RA and cardiovascular disease and cancer had higher disease activity at the study start only.

Patients with early RA often have other conditions that are linked to inflammation associated to varying degrees with early disease presentation, treatment, and worse RA activity over time. More studies are needed to determine if treatment for more than one condition rather than just one inflammatory condition may provide better outcomes for people living with early RA.


Outcomes of Aboriginal Patients with Early Inflammatory Arthritis: A CATCH Study Analysis

Sujay Nagaraj1, Cheryl Barnabe1, Orit Schieir2, Vivian Bykerk3, Janet Pope4, Susan Bartlett5, Gilles Boire6, Edward Keystone7, Diane Tin8, Boulos Haraoui9, Carter Thorne8, Carol Hitchon10, Canadian Early Arthritis Cohort (CATCH) Investigators. 

1University of Calgary, Calgary; 2University of Toronto, Toronto; 3Hospital for Special Surgery, New York; 4Western University, London; 5McGill University, Montreal; 6Université de Sherbrooke, Sherbrooke; 7Mount Sinai Hospital, University of Toronto, Toronto; 8Southlake Regional Health Centre, Newmarket; 9Institut de Rhumatologie de Montréal, Montreal; 10University of Manitoba, Winnipeg.

 

Aboriginal patients who have chronic diseases often experience health inequities. This study compared Aboriginal and Caucasian patients with early inflammatory arthritis in terms of disease presentation, treatment, and outcomes over five years. The researchers observed differences in disease characteristics in Aboriginal patients and worse disease outcomes. Even when treated with the same approaches as Caucasians, Aboriginals did not have the same frequency of remission. The results may reflect disparities in social and economic status and differences in environmental exposures associated with worse disease outcomes. The results may also show the need to re-evaluate the use of the same treatment approaches being applied in different population contexts.

Read more

What was the purpose of the study?

Aboriginal patients who have chronic diseases often experience health inequities. This study compared Aboriginal and Caucasian patients with early inflammatory arthritis in terms of disease presentation, treatment, and outcomes over five years.

How was this study done?

Participants in CATCH who identified as Aboriginal or Caucasian were compared in terms of demographics, clinical characteristics, therapeutic approach and frequency of remission. Measures such as disease activity score (also called DAS28), health assessment questionnaire (HAQ), and patient-reported outcomes and tender and swollen joint counts were examined over five years.

What were the results of the study?

There were 100 Aboriginal and 2,073 Caucasian participants. Socioeconomic and demographic factors such as smoking status, body mass index, education, household income, did not favour Aboriginal patients’ outcomes. The frequency of use of therapeutic approaches and escalation was not different between groups. DAS28 remission occurred less frequently in Aboriginal participants at visits up to 36 months:

  • At 3 months 16% of Aboriginal participants were in remission compared to 30% of Caucasian participants;
  • At 6 months 17% of Aboriginal participants were in remission compared to 41% of Caucasian participants;
  • At 12 months 16% of Aboriginal participants were in remission compared to 50% of Caucasian participants;
  • At 18 months 24% of Aboriginal participants were in remission compared to 53% of Caucasian participants;
  • At 24 months 29% of Aboriginal participants were in remission compared to 58% of Caucasian participants; and
  • At 36 months 40% of Aboriginal participants were in remission compared to 59%, of Caucasian participants.

Aboriginal participants had higher DAS28 scores (which means more active RA) because of slower improvement in swollen joint counts and the lack of improvement in patient global scores. Although HAQ and pain scores improved in both groups, fatigue did not improve in Aboriginal participants.

The researchers observed differences in disease characteristics in Aboriginal participants and worse disease outcomes. Even when treated with the same treatment approaches as Caucasians, Aboriginals did not have the same frequency of remission. The results may reflect disparities in social and economic status and differences in environmental exposures associated with worse disease outcomes. The results may also show the need to re-evaluate on the use of the same treatment approaches being applied in different population contexts.


Patient Characteristics, Treatment Strategy or Investigator Effect: An Analysis of Factors Driving Variation in Outcomes in Early Rheumatoid Arthritis

Cheryl Barnabe1, Orit Schieir2, Glen Hazlewood1, Susan J. Bartlett3, Carol A Hitchon4, Janet E. Pope5, Gilles Boire6, Edward Keystone2, Diane Tin7, Boulos Haraoui8, Vivian P. Bykerk9, Carter Thorne2 and Canadian Early Arthritis Cohort (CATCH) Investigators.

1University of Calgary; 2University of Toronto; 3McGill University; 4University of Manitoba; 5University of Western Ontario; St. Joseph's Health Care; 6Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke; 7Southlake Regional Health Centre; 8Institut de Recherche en Rhumatologie de Montréal (IRRM); 9Mt Sinai Hospital.

Patient outcomes in early rheumatoid arthritis are largely thought to be due to individual factors of disease and how their RA is treated. The CATCH researchers thought that an additional factor may be the healthcare provider themself, who could influence patient outcomes through their own educational and practice experience, their approach to interacting with patients, and resources available in their practice. In an analysis of patients across 11 early rheumatoid arthritis clinics, we measured patient outcomes by looking at rates of remission, and found significant differences in rates of remission. The researchers determined that individual patient RA disease factors contribute greatly to the differences in remission, with treatment strategy and rheumatologist and clinic characteristics having less of a role in remission.

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What was the purpose of the study?

Patient disease outcomes in early RA are mainly thought to be due to a person’s RA disease characteristics as well as how their RA is treated. The CATCH researchers think that a person’s RA outcomes may also be affected by their healthcare provider. Their healthcare provider could influence disease outcomes through their own educational and practice experience, how they interact with patients, and resources in their clinic (such as if they have other members of their team, etc.). The researchers have looked at remission as a disease outcome across 11 different clinics. The study shows differences in rates of remission in patients who are treated at different clinics and the researchers looked at individual patient characteristics, treatment of their RA, and healthcare provider to understand these differences.

 

How was this study done?

Patients were included in the study if they had more than one year of follow-up data in their file, were regularly seen at a rheumatology clinic that had more than 40 patients in the study at the start, and had more than 30 patients with 2 years of follow-up data. The investigators looked at how many patients at each clinic were in DAS28 remission at one year, as well as patient characteristics including age, sex, symptom duration at the start of treatment for RA, education, comorbidities, if they smoked or not, if they were seropositive or not and DAS28 and HAQ scores at the study start; the type of medications taken – which was also called treatment strategy (and was broken down in to the following treatment strategies: methotrexate pills, injected methotrexate, methotrexate and other medications, triple therapy (which is a term for taking methotrexate, plaquenil and sulfasalazine together), biologic therapy, and steroid; and clinic characteristics (how many patients the clinic has in the CATCH study, if the clinic is part of an academic centre; if the rheumatologist practices alone or with a group of others; if other healthcare professionals are employed at the clinic such as nurses, occupational or physiotherapists, etc.), if there is teaching at the clinic; and the proportion of rheumatologist researchers at that site by sex.

 

What were the results of the study?

1,633 patients were in the study who were on average 54 years old, and 73% were female with an average DAS28 of 4.9 (which means they had active RA symptoms). At one year, 49% of patients across all the clinics in the study had reached DAS28 remission (with a range at the clinics from 22%-80% of patients reaching remission) and the frequency of sustained DAS28 remission (which means remission for over 6 months) over all subsequent clinic visits was 52% (with a range at the clinics from 29%-71% of patients reaching sustained remission). There were significant differences between clinics in the types of patient characteristics and frequency of use of medications:

  • 6% of patients used injected methotrexate;
  • 36% of patients used a methotrexate-based combination of medications;
  • 11% of patients used triple therapy, and
  • 14% of patients used biologics.

Other interesting findings were:

  • 73% of clinics were affiliated with an academic centre,
  • 45% of clinics had patients seen by a rheumatologist and also by other healthcare professionals,
  • 82% of clinics included teaching at their site,
  • 64% of clinics were part of the CATCH study who had an average of 5 CATCH researchers at their site, and
  • 62% of the rheumatologist researchers were female.

Patient characteristics of age, sex, comorbidities, smoking status, seropositive status, baseline DAS28 scores were all important factors in remission. The specific treatment strategy had no significant effect on remission, except for when oral steroids were used. Clinics that were teaching sites had a negative impact on remission of patients at the clinic.

The researchers determined that individual patient RA disease factors contribute greatly to the variation in remission outcomes, with treatment strategy and rheumatologist and clinic characteristics having less of a role in remission outcome of patients.


Sex, Smoking and Excess Weight: Effects on DAS28 Trajectories in the First 2 Years in RA

Susan Bartlett1, Orit Schieir2, Kathleen Andersen3, Gilles Boire4, Boulos Haraoui5, Carol Hitchon6, Edward Keystone7, Janet Pope8, Carter Thorne9, Diane Tin9, Vivian Bykerk10, CATCH Canadian Early Arthritis Cohort Investigators.

1McGill University, Montreal; 2University of Toronto, Toronto; 3McGIll University, 4Université de Sherbrooke, Sherbrooke Beaconsfield; 5Institut de Rhumatologie de Montreal, Montréal; 6University of Manitoba, Winnipeg; 7Mount Sinai Hospital, University of Toronto, Toronto; 8Western University, London; 9Southlake Regional Health Centre, Newmarket; 10Hospital for Special Surgery, New York.

Early, aggressive treatment of rheumatoid arthritis with the goal of getting a person in to remission is associated with better long-term outcomes for people with RA. The CATCH study has shown that people who smoke and have excess weight are less likely to achieve sustained remission within the first 3 years after their RA diagnosis. Being female, overweight or obese, and being a current or former smoker significantly decreased the rate that RA disease activity improved over the first 2 years. These results show the potential value of stopping smoking and achieving a healthy weight early in the course of RA to optimize managing one's RA and to improve outcomes.

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What was the purpose of the study?

Early, aggressive treatment of RA aiming for to help a person get to remission is associated with better long-term outcomes of RA. CATCH has shown that people who smoke and have excess weight are less likely to achieve sustained remission within the first 3 years of their diagnosis. This study looked at how smoking, excess weight, and sex impacted the rate of RA disease activity improvement (measured by the DAS28) in the first 2 years of early RA.

How was this study done?

CATCH participants were part of the study if they had RA (as defined by the 1987 or 2010 ACR criteria for RA), had symptoms for less than one year and a disease activity score (DAS28) of greater than or equal to 2.6, had Body Mass Index (also called BMI) and DAS28 measurements at the study start and at least 1 follow-up appointment. We wanted to know how sex, excess weight (measured with BMI) and smoking status (that is: current, former, or never a smoker) affected disease activity at the study start and over time.

What were the results of the study?

There were 1109 patients in the study with an average: age of 53 years; symptom duration of 5 months; DAS28 of 5.3; and, health assessment questionnaire disability index (HAQ-DI) of 1.1. 72% of participants were female. Of the men in the study:

  • 44% were overweight,
  • 35% were obese, and
  • 22% smoked.

Of the women in the study:

  • 31% were overweight,
  • 32% were obese, and
  • 15% smoked.

At the study start 88% of participants were taking disease modifying anti-rheumatic drugs (also called DMARDs) and 73% were taking methotrexate.

Results showed that sex, excess weight, and smoking were not significantly associated with a person’s disease activity at the study start. However, each of those factors impacted disease activity over time. The average rate of disease activity improvement at each time point was lower in women than in men, and was worse for overweight and obese people compared to people who were a healthy weight. People who never smoked had improved rates of disease activity compared to people who are smokers or who used to smoke.

These results show that smoking and excess weight are common in people with early RA. Being female, overweight or obese, and a current or former smoker significantly negatively affected improvement of RA disease activity over the first 2 years. These results show that lifestyle may affect outcomes of RA, and the potential value of stopping smoking and achieving a healthy weight early in the course of RA to help manage one’s RA and improve outcomes. These findings are important because it is not generally thought that people can do anything about their RA, but that in fact, there are some factors they can control to help their RA.


Site Variation in Early Treatment Strategies and DAS28 Remission at 6 Months in the Canadian Early Arthritis Cohort (CATCH)

Cheryl Barnabe1, Orit Schieir2, Glen Hazlewood1, Janet Pope3, Carol Hitchon4, Susan Bartlett5, Gilles Boire6, Edward Keystone7, Diane Tin8, Boulos Haraoui9, Vivian Bykerk10, Carter Thorne8, Canadian Early Arthritis Cohort (CATCH) Investigators.

1University of Calgary, Calgary; 2University of Toronto, Toronto; 3Western University, London, 4University of Manitoba, Winnipeg; 5McGill University, Montreal; 6Université de Sherbrooke, Sherbrooke; 7Mount Sinai Hospital, University of Toronto, Toronto; 8Southlake Regional Health Centre, Newmarket; 9Institut de Rhumatologie de Montréal, Montreal; 10Hospital for Special Surgery, New York.

The study compared practice differences in the treatment of early arthritis in rheumatology clinics across Canada to see if associations could be made with the number of early RA patients achieving disease activity score (also called DAS28) remission at 6 months. Compared to methotrexate only (in pill form), methotrexate combination therapy, methotrexate (injected), non-methotrexate disease modifying anti-rheumatic drug (also called DMARD) combination therapy and biologic therapy were all associated with higher odds of DAS28 remission. Household income of more than $50,000 per year was also associated with higher odds of DAS28 remission. The following characteristics were related to lower odds of achieving DAS28 remission: taking steroids, being female, having more comorbidities, being non-Caucasian, being older, having symptoms for longer, and, high disease activity at the study start. Treatment approaches and patient characteristics vary across clinics that are participating in the CATCH study and contribute to different rates of remission at 6 months.

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What was the purpose of the study?

The study compared practice differences in the treatment of early arthritis in rheumatology clinics across Canada to see if associations could be made with the number of early RA patients achieving DAS28 remission at 6 months.

How was this study done?

Data were looked at for rheumatology centres that are part of the Canadian Early Arthritis Cohort (CATCH) study and which had enrolled at least 40 participants in to CATCH. The researchers looked at associations between early treatment approaches (conventional DMARDs, biologic DMARDs and steroids at study start or within 3 months of the study start), participant characteristics (age, gender, income, education, comorbidities, smoking status, ethnicity, seropositive status, body mass index, symptom duration and DAS28 at start), site size (that is, how many patients are seen at a clinic) and DAS28 remission at 6 months.

What were the results of the study?

The study included 1,929 participants and 16 centers. There were significant differences between centers in participant characteristics (gender, age, symptom duration, body mass index, comorbidities, smoking status, education, ethnicity, marital status, seropositive status, erosions), study start disease activity measures and early treatment approaches. In order of frequency of use in percentage of participants, the medication use strategies were:

  • methotrexate-based combination therapy in 36% (site range was 11%-67%)
  • methotrexate monotherapy in 33% (taken as a pill in 17% (site range was 4%-61%), and taken as an injection in 16% (site range was 0%-49%))
  • non-methotrexate DMARDs in 15% (site range was 0%-33%)
  • triple therapy (which means methotrexate, plaquenil, and sulfasalazine) in 13% (site range was 0%- 64%), and
  • biologics in 3% (site range was 0%-21%).

Overall, 61% of participants used steroids (delivered via different methods - that is, pill or injection) in the first 6 months of treatment (site range was 22%-78%). At 6 months, 37% of participants across all sites had achieved DAS28 remission (site range was 13%-65%).

Compared to methotrexate only (in pill form), methotrexate combination therapy, methotrexate (injected), non-methotrexate DMARD combination therapy and biologic therapy were all associated with higher odds of DAS28 remission. Household income of more than $50,000 per year was also associated with higher odds of DAS28 remission. The following characteristics were related to lower odds of achieving DAS28 remission: taking steroids, being female, having more comorbidities, being non-Caucasian, being older, having symptoms for longer, and, high disease activity at the study start.

Treatment approaches and patient characteristics vary across clinics that are participating in the CATCH study and contribute to different rates of remission at 6 months.


The OMERACT RA Flare Questionnaire (RA-FQ) is Responsive to Change in RA Symptoms and Impacts

Susan Bartlett1, Vivian Bykerk2, Bruno Fautrel3, Francis Guillemin4, Alfons den Broeder5, Rieke Alten6, Robin Christensen7, Ernest Choy8, Daniel Furst9, Sarah Hewlett10, Amye Leong11, Lyn March12, Thasia Woodworth9, Clifton Bingham13, Canadian Early Arthritis Cohort (CATCH) Investigators.

1McGill University, Montreal; 2Hospital for Special Surgery, New York; 3APHP, Paris; 4Université de Lorraine, Nancy; 5Sint Maartenskliniek, Ubbergen; 6Charite University, Berlin, Berlin; 7Parker Institute, Frederiksberg; 8Cardiff University, Cardiff; 9University of California Los Angeles, Los Angeles; 10University of the West of England, Bristol; 11Healthy Motivation, Santa Barbara; 12The University of Sydney, Sydney; 13Johns Hopkins, Baltimore.

The researchers have previously shown the validity and reliability of the RA Flare Questionnaire (RA-FQ), a new tool that measures the symptoms and impacts of RA flares. This study evaluates the RA-FQ in a clinical trial and two observational studies of RA patients who were initially in remission or low disease activity. Data from clinical and observational studies support the responsiveness of the RA-FQ in detecting change over time. The RA-FQ detects worsening of RA symptoms and impacts consistent with an increase in disease activity, and this supports its use in research and clinical care.

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What was the purpose of the study?

The researchers have previously showed the validity and reliability of the RA Flare Questionnaire (RA-FQ), a new tool that measures the symptoms and impacts of RA flares. This study evaluated the RA-FQ in a clinical trial and two observational studies of RA patients who were initially in remission or low disease activity. Data from the studies support that the RA-FQ detects change over time. The RA-FQ detects worsening of RA symptoms and impacts consistent with an increase in disease activity, and can be used in research and clinical care.

How was this study done?

RA patients in two observational studies (CATCH in Canada and STPR in France), and a randomized clinical trial in the Netherlands (called DRESS) completed the 5-items on the questionnaire, indicating if they were in a flare, and if so, the severity and length of time of the flare. Within each study, patients were selected who said they were not in flare and had a disease activity score (also called DAS28) of less than 3.2 at the first visit. Flare at the second visit was defined three ways: 1) by asking the patient if they were in a flare (a yes/no response); 2) patient report-stringent (where the patient reported yes AND severity AND duration; and c) disease activity score definition. The researchers compared the average change in RA-FQ scores and other patient-reported outcomes and clinical measures of disease activity between patients who were in a flare and those who were not.

What were the results of the study?

The average difference in RA-FQ scores at the second visit ranged from 7.3 in the French trial using the DAS definition to 19.6 in the Canadian trial using the patient report-stringent method (see above). The average difference sizes were largest for patient report-stringent in 2 of 3 studies. The average differences were also strong for patient global, MD global, HAQ, DAS28, and other clinical indicators except ESR.

Data from clinical and observational studies support the responsiveness of the RA-FQ in detecting change over time. The RA-FQ reliably detects worsening of RA symptoms and impacts that correlate with an increase in disease activity, and support its use in research and clinical care.


The RA Flare Questionnaire (RAFQ) is Responsive to Change in RA Symptoms and Impacts in Clinical and Observational Trials

S.J. Bartlett1,2, V.P. Bykerk3, B. Fautrel4, F. Guillemin5, A. den Broeder6, R. Alten7, R. Christensen8, E. Choy9, D. Furst10, S. Hewlett11, A. Leong12, L. March13, T. Woodworth10, B.I.O. Clifton1, on behalf of CATCH, STPR, & DRESS Investigators

1Johns Hopkins, Baltimore; 2McGill University, Montreal; 3Hospital for Special Surgery, New York; 4Pierre & Marie Curie Université, Paris; 5Université de Lorraine, Nancy; 6Maartens Kliniek, Nijmegen; 7Schlosspark Klinik, Berlin; 8Parker Institute, Copenhagen; 9Cardiff University, Cardiff; 10UCLA, Los Angeles; 11University of the West of England, Bristol; 12Healthy Motivation, Santa Barbara; 13University of Sydney, Sydney.

The RA-FQ is a tool to measure RA flares. The researchers have already shown that it measures flares in a valid and reliable way. The researchers now wanted to measure sensitivity to change of the RA-FQ in clinical trials and observational studies of RA patients with low disease activity. Data from clinical and observational studies in Canada, France, and the Netherlands were used to show the responsiveness of the RA-FQ in detecting change over time. The RA-FQ is able to detect worsening of RA symptoms that show increased disease activity in patients. The use of the RA-FQ scale is supported in research and clinical care given how it has been shown to work.

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What was the purpose of the study?

The RA-FQ is a tool to measure RA flares. The researchers have already shown that it measures flares in a valid and reliable way. The researchers now wanted to measure sensitivity to change of the RA-FQ in clinical trials and observational studies of RA patients with low disease activity.

How was this study done?

RA patients in observational studies in Canada (896 participants) and France (138 participants), and a clinical trial in the Netherlands (178 participants) completed 5 items asking whether or not they were in flare, and if they were, the severity and duration of their flare. Patients who said they were not in flare and had a disease activity score (DAS28) of less than 3.2 at the first visit were selected for further study. Flare at the second visit was defined three ways:

1) the patient reported if they were in a flare or not;

2) the patient reported that they were in a flare, indicated a flare severity of at least 4 out of a possible 10 points, and the flare had been occurring for at least 7 days (this was called ‘patient report stringent’  and to increase this reflected increased inflammatory disease activity); and

3) Disease activity score (DAS) definition often used in research studies. If the DAS28 was less than 3.2 at the second visit, it required an increase of 1.2, and if the DAS28 was greater than or equal to 3.2, it required an increase of 0.6. The researchers compared RA-FQ scores with other patient-reported outcomes and disease activity indicators between flaring and non-flaring patients at the second visit. The researchers thought that at the second visit, RA-FQ scores would be similar in patients not flaring at both visits, and would be significantly higher in those flaring at the second visit.

 What were the results of the study?

The average difference in RA-FQ scores at the second visit ranged from 7.3 in participants in France to 19.6 for participants in Canada (patient report-stringent). The data analysis showed that the patient reported stringent definition of flare produced the most sensitive results for the RA-FQ. The RA-FQ was also able to detect changes in RA symptoms with the patient global, physician global, and health assessment questionnaire, DAS28, and other clinical indicators except erythrocyte sedimentation rate.

Data from clinical and observational studies support the responsiveness of the RA-FQ in detecting change over time. The RA-FQ is able to measure psychometric properties and also detects worsening of RA symptoms that show increased disease activity in patients. The use of the RA-FQ scale is supported in research and clinical care given how it has been shown to work.


The Rheumatoid Arthritis Flare Questionnaire (RA-FQ): Results of Rasch Analysis and Feedback on Real-World Applications from International RA Patients and Clinicians

S.J. Bartlett1,2, S.P. Barbic3, V.P. Bykerk4, B. Fautrel5, F. Guillemin6, A. den Broeder7, R. Alten8, R. Christensen9, E. Choy10, D. Furst11, S. Hewlett12, A. Leong13, L. March14, T. Woodworth11, B.I.O. Clifton2, on behalf of CATCH, STPR, & DRESS Investigators 

1McGill University, Montreal; 2Johns Hopkins, Baltimore; 3University of British Columbia, Vancouver; 4Hospital for Special Surgery, New York; 5Pierre & Marie Curie Université, Paris; 6Université de Lorraine, Nancy; 7Maartens Kliniek, Nijmegen; 8Schlosspark Klinik, Berlin; 9Parker Institute, Copenhagen; 10Cardiff University, Cardiff; 11UCLA, Los Angeles; 12University of the West of England, Bristol; 13Healthy Motivation, Santa Barbara; 14University of Sydney, Sydney.

Flares in RA are common. The RA Flare Questionnaire (RA-FQ) is a tool that can be used to identify and quantify flares. This study aimed to explore the psychometric properties of the RA-FQ by using a method called Rasch analysis. The results were reviewed with RA patient research partners and clinicians to gain more insight into the interpretability, meaningfulness, and use of results. Results show that the RA-FQ measures psychometric properties well and its 5-items are easy to complete and simple to score. Feedback from RA patient research participants and clinicians increase confidence in the relevance, meaningfulness, and easy interpretation of RA-FQ results.

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What was the purpose of the study?

Flares in RA are common. The RA Flare Questionnaire (RA-FQ) is a tool that can be used to identify and quantify flares. This study aimed to explore the psychometric properties of the RA-FQ by using Rasch analysis. The results were reviewed with RA patient research partners and clinicians to gain more insight into the interpretability, meaningfulness, and use of results.

How was this study done?

People with RA in observational trials in Canada (896 participants) and France (138 participants), and clinical trial in the Netherlands (178 participants) completed the RA-FQ. A number of statistical and data analysis tools were also used to check the tool. The researchers also reviewed results with RA patient research partners to gain additional insight into the interpretability, meaningfulness, and utility of results. Ten patient research partners first completed the questionnaire then reviewed individual and group findings to provide feedback. RA clinicians provided feedback on utility and relevance as well.

What were the results of the study?

Rasch results supported the survey scoring method of simply summing each survey item in to a total score that ranged from 0–50. The RA-FQ’s reliability was high (which means it measured things the same regardless of who answered) and questions were determined to be well-targeted to respondents. The survey worked well and results were trustworthy no matter the respondent’s sex, age, or country/language. Items asked on the survey suggest flare symptoms and impacts increased together and showed a consistent story of how people experience worsening RA disease activity. There was full agreement from the patients that the story depicted and results obtained were easily understood, meaningful, and depicted their current state. Several patient research partners noted that the survey could help them with communicating with their doctors, monitoring their RA daily, and with self management.

Results from the analyses support that the RAFQ does a good job of measuring psychometric properties. The 5-items measured are easy to complete and simple to score. Feedback from patient research participants and clinicians increase confidence in the relevance, meaningfulness, and easy interpretation of results.


Time to Remission and the Achievement of Sustained Remission in Patients with Early Rheumatoid Arthritis: Site Variation Analysis in Therapeutic Strategy from the Canadian Early Arthritis Cohort (CATCH)

C. Barnabe1, O. Schieir2, G. Hazlewood3, J. Pope4, C. Hitchon5, S. Bartlett6, G. Boire7, E. Keystone2, D. Tin8, B. Haraoui9, V. Bykerk10, C. Thorne8 on behalf of Canadian Early Arthritis Cohort (CATCH) Investigators

1University of Calgary, Calgary; 2University of Toronto, Toronto; 3Medicine, University of Calgary, Calgary; 4Western University, London; 5University of Manitoba, Winnipeg; 6McGill University, Montreal; 7University of Sherbrooke, Sherbrooke; 8South lake Regional Health Centre, Newmarket; 9Universite de Montreal, Montreal; 10Hospital for Special Surgery, New York.

 

Different patients respond differently to medications. Therapies recommended to patients are often based on their healthcare provider’s experiences and beliefs, and how a person’s RA responds to these therapies is very dependent on a number of different characterists. When many patients from different sites across the country are involved in a study such as CATCH, these differences in treatment will be reflected in the study’s data. The CATCH researchers looked at differences in treatment by examining remission in patients based on measuring it with the Clinical Disease Activity Index (also called CDAI) or Disease Acvitity Score (also called DAS28) remission and how often patients experience sustained remission. As suspected, the way RA is treated and patient characteristics was found to vary across CATCH sites and contribute to different rates and frequency of achieving sustained remission.

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What was the purpose of the study?

Different patients respond differently to medications. Therapies recommended to patients are often based on their healthcare provider’s experiences and beliefs, and how a person’s RA responds to these therapies is very dependent on their RA. In turn, this may lead to variations in the length of remission or the time it takes to get to remission based on where someone receives care. For studies (also called cohorts) that involve patients from many different sites, different effects may be seen. The researchers looked at how patients were treated at many sites by comparing remission based on the Clinical Disease Activity Index (also called CDAI) and Disease Acvitity Score (also called DAS28) definitions, and how often patients experience sustained remission.

How was this study done?

In order to be in the study, patients needed to have more than 1 year of follow-up data. Sites that were participating in the study had more than 40 patients at the study start and more than 30 patients with 2 years of follow-up data. The researchers looked at the time to get to remission and the frequency of sustained remission (2 consecutive visits at least 6 months apart), using DAS28 and CDAI scores. The researchers looked at different treatment approaches from site to site and classified them as: initial use of oral methotrexate; subcutaneous methotrexate; combinations that included methotrexate, disease modifying anti-rheumatic drugs (DMARDs) other than methotrexate; triple therapy (which means a combination of plaquenil, sulfasalazine and methotrexate); or biologic therapy.

What were the results of the study?

There were 1,749 participants from 13 sites in the study. The average participant age was 54 years, 73% were female, the average DAS28 score was 4.9 and the average CDAI score was 25.6. There were significant differences between sites in terms of participant characteristics (gender, age, symptom duration, body mass index, comorbidities, smoking status, education, ethnicity, marital status, seropositive status, erosions). At the start of the study:

  • 16% of participants were taking oral methotrexate only and this ranged from 0% to 55% across all the sites;
  • 15% of participants were taking subcutaneous methotrexate, and this ranged from 0% to 45% across all sites;
  • 30% of participants were on some form of therapy that included methotrexate, and this ranged from 10% to 47% across all sites;
  • 19% of participants were taking DMARDs other than methotrexate DMARDs, and this ranged from 4% to 44% across the sites;
  • 11% of participants were on triple therapy, and this ranged from 0% to 60% across all sites; and,
  • 2% of participants were on biologics, and this ranged from 0% to 18% across all sites.  

At 5 years, the use of these treatment approaches was relatively the same except for the use of biologics: now 21% of participants were taking biologics, and which ranged across the sites from 0% to 80%. The average time from study start for a participant to reach remission based on the DAS28 score was 12.4 months, while if the CDAI score was used to define remission, the average time to get to remission was slightly longer at 14.8 months. The frequency of sustained DAS28 remission was 50% (and ranged at sites from 20 to 70%), and for CDAI sustained remission it was 35% (and ranged at sites from 12 to 58%).

At the two sites with the highest rates of sustained remission and shortest time to remission, patients had fewer comorbidities and the initial treatment approach was usually a combination that included methotrexate, and with eventual advancement to biologics in 7 and 39% of patients at these 2 sites. The patients at the site with the lowest rates of sustained remission and longest time to remission had patients who: experienced symptoms for a long time before treatment started, had the highest body mass index; had the most comorbidities; had low socioeconomic status; and had higher baseline DAS28 (indicating high RA disease activity). This site also had the highest proportion of patients treated with biologics at the start, reaching 80% by 5 years.

How RA is treated and patient characteristics vary across CATCH sites and contribute to different rates and frequency of achieving sustained remission.


Time Trends over a Decade Show Earlier Intensified Medication Strategies and Improved Outcomes in Canadians with Early Inflammatory Arthritis

Orit Schieir1, Marie-France Valois2, Susan J. Bartlett2,3, Carol A Hitchon4, Janet E. Pope5, Gilles Boire6, Boulos Haraoui7, Diane Tin8, Carter Thorne1, EC Keystone1,9, Vivian P. Bykerk9,10 and Canadian early ArthriTis CoHort (CATCH) Investigators.

1University of Toronto; 2McGill University; 3Johns Hopkins University School of Medicine; 4University of Manitoba; 5University of Western Ontario, St Joseph's Health Care; 6Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke; 7Institute de Rheumatologie; 8Southlake Regional Health Centre; 9Mount Sinai Hospital; 10Divison of Rheumatology, Hospital for Special Surgery.

Treatment recommendations are created for healthcare professionals to help them improve outcomes for people who live with rheumatoid arthritis (RA) through early identification of RA and an approach called treat-to-target. The CATCH researchers looked at trends over the past 10 years including patient characteristics, treatment strategies and disease activity in the first year of follow-up in the CATCH cohort. The researchers looked at any trends in patient characteristics, early treatment approaches that included medications such as conventional disease modifying anti-rheumatic drugs (DMARDs) and biologic DMARDs and disease activity and related measurements over 1 year. The researchers also looked at which factors could help them understand which patients may not reach a low disease activity or remission by one year and the characteristics those patients had in common. This study results suggest that earlier, more intense treatment that is promoted in treatment recommendations has resulted in lower disease activity and a greater number of patients reaching the target of therapy. However, still 25-30% of patients were not experiencing a low disease state or remission by one year.

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What was the purpose of the study?

Treatment recommendations are created for healthcare professionals to help them improve outcomes for people who live with rheumatoid arthritis (RA) through early identification of RA and an approach called treat-to-target. The CATCH researchers looked at trends over the last 10 years including patient characteristics, treatment strategies and disease activity in the first year of follow-up in the CATCH cohort.

How was this study done?

Participants in the study had their RA symptoms for less than one year, and their clinical files had DAS28 measures at 6 and 12-months. All patients had regular rheumatology visits including clinical assessments, answering questionnaires, and blood tests or other tests every 3 months for the first year. Treatment of patients was ultimately up to the patient’s rheumatologist and these rheumatologists met once a year to discuss how to improve outcomes in their patients.

The researchers looked at any trends in patient characteristics, early treatment approaches that included medications such as conventional DMARDs and biologic DMARDs and disease activity outcomes over 1 year. The researchers also looked at which factors could help them understand which patients may not reach a low disease activity or remission by one year and the characteristics those patients had in common.

What were the results of the study?

There were 2,822 patients in the study with 70% of them being women and 80% were Caucasian. At the start of the study, 86% were diagnosed with RA based on meeting the 1987 or 2010 American College of Rheumatology/European League Against Rheumatism RA criteria; and they were an average of 54 years old and had their symptoms for about 6 months. 92% were on conventional DMARDs with 77% on some type of methotrexate treatment (which could be methotrexate alone or in combination with other medications); 29% were prescribed oral steroids and 27% were taking steroids by injection.

The characteristics of patients entering CATCH changed slightly over time and included increases in age, male sex, education, income, and a decline in number of patients who smoke. Over time, patients starting CATCH had fairly stable obesity rates, comorbidities and RA characteristics (including their serology, inflammatory markers, joint counts and disease activity measurements). 87% of participants started the study with RA that had moderate or high activity, and disease activity at 6 months and one year improved greatly over time. Over time, patients identified to be in DAS28 remission at 1 year increased by over 30% and 20% more patients had low disease activity or were in remission by 6 months.

Looking at medication and treatment trends over time showed treatment with methotrexate being increased to above 20 mg sooner, more use of methotrexate by injection versus pills, and earlier methotrexate combination therapies and more rapid use of biologics. People whose RA remained at mostly moderate or high disease activity at one year had a number of common characteristics, including: being older in age, being female, having a lower education, being non-white, having a body mass index (also called BMI) score that classified them as being as overweight or obese, and having more comorbidities.

This study of Canadian early RA patients over time suggests that earlier, more intense treatment that is encouraged by treatment recommendations has resulted in lower disease activity and a greater proportion of patients reaching the target of therapy. However, about 25-30% of patients are still not experiencing a low disease state or remission by one year. 


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

Babak Aberumand1, Orit Schieir2, Lyne Nadeau3, Vivian Bykerk4, Gilles Boire5, Boulos Haraoui6, Carol Hitchon7, Carter Thorne8, Diane Tin8, Edward Keystone9, Susan Bartlett10, Janet Pope11

1Schulich School of Medicine and Dentistry, London, London; 2University of Toronto, Toronto; 3McGill University, Montreal; 4Hospital for Special Surgery, New York; 5Université de Sherbrooke, Sherbrooke; 6Institut de Rhumatologie de Montreal, Montréal; 7University of Manitoba, Winnipeg; 8Southlake Regional Health Centre, Newmarket; 9Mount Sinai Hospital, University of Toronto, Toronto; 10McGill University, Montreal; 11Western University, London.

Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) are found in a person’s blood and may affect how they respond to medications they take for their early rheumatoid arthritis (ERA). We looked at people whose RA was classified as seropositive or seronegative based on the presence of RF and/or ACPA to see if there were differences in how they responded to taking methotrexate and disease modifying anti-rheumatic drugs (also called DMARDs). Overall we found that people with early arthritis responded well to triple therapy (that means 3 types of medications taking together) if they were seropositive, while people who were seronegative responded better to methotrexate and lefluonide. 

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What was the purpose of the study?

Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) are found in a person’s blood and may affect how they respond to medications they take for their early RA. We looked at people whose RA was classified as seropositive or seronegative based on RF and/or ACPA to see if there were differences in how they responded to taking methotrexate and other DMARDs.

How was this study done?

Participants in the CATCH study were included if they had measurements available on their RF, ACPA, and DAS28 at the study start and at their 3- and 6-month appointments. The researchers looked at the change in DAS28 and health assessment questionnaire - disability index (HAQ-DI) and the percent of patients who were considered to be in DAS28 remission at 3- and 6-months and compared RF positive to RF negative, ACPA positive to ACPA negative, and RF positive or ACPA positive to RF negative and ACPA negative, respectively. The researchers also looked at what medications people were on for their RA, and those were: methotrexate alone, methotrexate and hydroxychloroquine, methotrexate and sulfasalazine, triple therapy (which means they were taking methotrexate, hydroxychloroquine and sulfasaline) and methotrexate and leflunomide.

What were the results of the study?

There were 1245 patients in the study and they had an average DAS28 of 5.3 at the study start. Of these patients, 774 were RF positive, 553 were ACPA positive and 856 were seropositive (RF positive and/or ACPA positive).

At the study start, the researchers did not see differences in disease activity and methotrexate-based treatments based on serology, however the researchers found differences in treatment response at 3-months. After 3 months, patients on triple therapy had a greater improvement in disease activity (measured by a change in DAS28) if they were RF positive compared to RF negative; ACPA positive compared to ACPA negative; and, seropositive compared to seronegative. Triple therapy was associated with higher DAS28 remission in RF positive patients compared to RF negative patients. However, RF positive patients had worse responses to treatment with methotrexate and lefluonide; and ACPA positive patients and seropositive patients responded better to methotrexate and hydroxychloroquine compared to seronegative patients. Any differences seen were not significant at 6-months.

Overall the researchers found that people with early arthritis responded well to triple therapy if they were seropositive, while people who were seronegative responded better to methotrexate and lefluonide. 


Trends and Predictors of Guideline Adherence for Glucocorticoid-induced Osteoporosis Prevention in an Early Rheumatoid Arthritis Cohort

Stephanie Gottheil1, Orit Schieir2, J. Carter Thorne3, Susan J. Bartlett4, 5, Gilles Boire6, Boulos Haraoui7, Carol Hitchon8, Diane Tin3, Edward Keystone2,9, Vivian P. Bykerk10, and Janet E. Pope1.

1University of Western Ontario; St. Joseph's Health Care; 2University of Toronto; 3Southlake Regional Health Centre; 4McGill University; 5Johns Hopkins University School of Medicine; 6Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke; 7Institute de Rheumatologie; 8University of Manitoba; 9Mount Sinai Hospital; 10Divison of Rheumatology, Hospital for Special Surgery.

RA patients are at a high risk of osteoporosis and fracture, partly due to using a type of medication called glucocorticoids to treat their RA. Treatment guidelines from the American College of Rheumatology (ACR) on prevention of glucocorticoid-induced osteoporosis recommends that RA patients use medication for osteoporosis, however this use remains low. This study looked at trends in anti-osteoporotic medication use over the past 10 years among early RA patients meeting guidelines for glucocorticoid-induced osteoporosis prevention, and to find predictors of guideline adherence. Treating according to glucocorticoid-induced osteoporosis prevention guidelines was not optimal and did not change over time. Higher RA activity was associated with proper treatment based on guidelines. Further research is needed to determine reasons that treatment according to guidelines does not occur and to develop strategies to improve prevention of glucocorticoid-induced osteoporosis.

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What was the purpose of the study?

RA patients are at a high risk of osteoporosis and fracture, partly due to using a type of medication calledglucocorticoids to treat their RA. Treatment guidelines from the American College of Rheumatology (ACR) on prevention of glucocorticoid-induced osteoporosis recommend that RA patients use medication for osteoporosis, however this use remains low. This study looked at trends in anti-osteoporotic medication use over the past 10 years among early RA patients meeting guidelines for glucocorticoid-induced osteoporosis prevention, and to find predictors that the guidelines were being followed.

How was this study done?

Participants in this study were from the CATCH cohort who were over 50 years old, without a diagnosis of osteoporosis at the start of the study, with at least 6 months of follow up data for analysis. Following glucocorticoid-induced osteoporosis guidelines was measured based on the use of bisphosphonate or denosumab (two medications to treat osteoporosis) in patients taking 7.5 mg or more of prednisone (a glucocorticoid) daily for more than 3 months. Prednisone is a glucocorticoid that is very effective to treat RA, but also puts patients at high risk of osteoporosis and fracture.     

What were the results of the study?

There were 1,468 participants in the study who were an average of 63 years old, 64% were women, and the average DAS28-erythrocyte sedimentation rate (also called ESR) was 5.0 (which means their RA was very active). Of this, 282 patients received 7.5 mg or more of prednisone daily for more than 3 months, and this number decreased over time. Overall, only 54 eligible patients received anti-osteoporotic medication and 105 patients received vitamin D. Patients who were using glucocorticords for a long time had a significantly higher likelihood of taking osteoporosis medication and vitamin D. A person’s DAS28 at study start significantly predicted guideline adherence, while their body mass index (also called BMI and which is a measurement of their weight and height) and glucocorticoid dose were less so to predict this.

In CATCH, approximately 1 in 5 patients met criteria for glucocorticoid-induced osteoporosis prevention according to treatment guidelines. Chronic use of glucocorticoids decreased over time, suggesting either less frequent use or faster tapering of these medications. Treating according to glucocorticoid-induced osteoporosis prevention guidelines was not optimal and did not change over time. Higher disease activity was significantly associated with proper treatment based on guidelines. Further research is needed to determine reasons that treatment according to guidelines does not occur and to develop strategies to improve prevention of glucocorticoid-induced osteoporosis.


Which Multimorbid Conditions are More Prevalent Around the Time of Early RA Diagnosis and have the Greatest Impact on Trajectories of Disease Activity in the First Year? Results from the Canadian Early Arthritis Cohort

O. Schieir1, S. J. Bartlett2, 3, C. Hitchon4, J. Pope5, G. Boire6, B. Haraoui7, E. Keystone1, D. Tin8, C. Thorne8, V. P. Bykerk1, 9 on behalf of Canadian Early Arthritis Cohort Canada (CATCH) Investigators

1University of Toronto, Toronto; 2McGill University, Montreal; 3Johns Hopkins University, Baltimore; 4University of Manitoba, Winnipeg; 5Western University, London; 6Universite de Sherbrooke, Sherbrooke; 7Institut de Rhumatologie de Montreal, Montreal; 8Southlake Regional Health Center, Newmarket; 9Hospital for Special Surgery, New York.

Having more than one health condition (called multimorbidity or comorbidity) is often seen in early RA patients and people with more RA disease activity often have more conditions. It is important to understand which specific conditions and the number of them that most affect how RA presents, early therapies, and disease activity over time. The study goal was to estimate how many multimorbid conditions are usually seen at ERA diagnosis and these conditions’ relationship to clinical characteristics, early treatment, and disease activity in the first year of follow up. Multimorbidity is common in ERA patients and was found to be related to higher RA disease activity initially, less improvement of RA symptoms over time, and a greater likelihood of being prescribed steroids for certain conditions. Managing multimorbidities and RA together may help achieve better RA outcomes for patients.

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What was the purpose of the study?

Having more than one health condition (called a multimorbidity or comorbidity) is often seen in early RA patients and people with more RA disease activity often have more conditions. It is important to understand which specific conditions and the number of them that most affect how RA presents, early therapies and disease activity over time. The study goal was to estimate the prevalence of multimorbid conditions at ERA diagnosis and their relationship to clinical characteristics, early treatment, and disease activity in the first year of follow up.

How was this study done?

The study looked at ERA patients (with symptoms for less than one year) who were diagnosed with RA because they met 1987 or 2010 RA criteria, and had at least two disease activity score (DAS28) measures in the first year. The following conditions at the study start were measured:

  • cardiovascular disease (CVD)
  • diabetes
  • cancer
  • pulmonary disease
  • bowel disease
  • other rheumatic diseases
  • psoriasis (self-reported by patients)
  • obesity (measured by body mass index), and
  • depressive symptoms (measured by a survey called the RAND-12).

Patients’ demographic and clinical characteristics in ERA and each condition were compared to patients who had only ERA at the start of the study. The researchers estimated effects of each condition on early use of RA treatments and on DAS28 over the first year.

What were the results of the study?

The study included 1,595 patients: 72% were female who were an average age of 54 years and who had 6 months of symptoms. At the study start, 1,434 patients were treated with conventional disease modifying anti-rheumatic drugs or DMARDs (76% took methotrexate and 2% took a biologic). More than 70% of ERA patients reported at least one multimorbidity and of those, more than 30% reported two or more multimorbidities. Patients with multimorbidities were often older and had higher RA disease activity at the study start. Patients with RA and cardiovascular disease or depressive symptoms had 60% and 90% higher odds of steroid use at the start, respectively. Compared to patients with ERA only, patients with:

  • diabetes, other rheumatic diseases or depressive symptoms, had higher disease activity at the study start measured by DAS28 scores and this improved less over time,
  • pulmonary disease, bowel disease, psoriasis or obesity had similar baseline DAS28 scores but less improvement over time; and
  • cardiovascular disease or cancer had higher baseline DAS28 scores but similar improvement over time.

Multimorbidity is common in ERA patients and associated with higher disease activity initially, less improvement over time, or both, and a greater likelihood of prescribing steroids for certain conditions. Managing multimorbidities along with RA may help achieve better patient outcomes.