Dr.Chandrashekara. S
Prof and Managing Director
ChanRe Rheumatology and Immunology Center and Research
Bangalore

Dr Vineeta Shobha,MD,DM
Professor & Head,
Department of Clinical Immunology & Rheumatology,
St John's Medical College Hospital,
Bangalore

Dear All,

The study titled ‘Factors influencing remission in rheumatoid arthritis patients: results from Karnataka rheumatoid arthritis comorbidity (KRAC) study’, published in the recent issue of international journal of rheumatic diseases (IJRD), is one of the landmark studies undertaken by the Indian Rheumatology Association (IRA) Karnataka Chapter. The study reflects the true potential of the organization in working as a well co-ordinated team to achieve the desired results. The cross-sectional prospective study was organized in an effort to address the lacunae in epidemiological data related to the presence of co-morbidities and to evaluate their relationship with different disease parameters.The study,involving 3247 subjects, was conducted across 13 academic and non-academic specialty units across Karnataka (India) over a period of 9 months. The survey was based on patient examination, data collection by history, and verification of health charts on a pre-evaluated structured proforma.

The study reported 40% prevalence of comorbidities in South Indian RA population, thereby highlighting the increasing disease burden. The most commonly observed comorbidities were hypertension (20.7%), diabetes mellitus (14.3%) and hypothyroidism (18.3%). Other comorbidities like hypercholesterolemia, bronchial asthma and chronic heart disease were prevalent in less than 5% population. Some of the limitations of the study were cross-sectional pattern and the consideration of only history and the proof of previous/current diagnosis for the assessment of presence of co-morbidities. In addition, there was no active evaluation to include the missed cases in routine care (data yet to be published).

The data collection included: disease activity at the time of study, medication history (including DMARD, corticosteroids and biologics), baseline patient characteristics, disease duration, patient follow-up on DMARD, and the clinical and serological features. Majority of the patients were treated with double DMARDs. The data analysis based on DAS (28) ESR score showed that 19.95% (n= 397) were in remission. The chances of achieving remission noted in different patients age categories were 59% in 30-39 years, 35.4% in 40-49 years and 19.7% in 50-59 years. Early treatment, dose escalation of DMARD and patient education are the key factors influencing remission.

Evaluation of the same data for extra-articular manifestations (EAM) reported very interesting findings. The prevalence of EAM noted in 1716 study participants was around 13%. Anemia was more common during the first two years of the disease (OR 1.465; p=0.047). The probability of other EAMs increased with increase induration of disease prior to the consultation of rheumatologist. The incidence was lower in patients with low disease activity (OR: 0.657) and higher with the presence of deformities (OR 2.1). The study corroborates the current concept of effective disease control to reduce the incidence/likelihood of EAM in RA patients (accepted for publication).

The data has validated the concept of ‘treat-to-target’ and recommends the attainment of DAS 28 ESR around 2.6 to reduce the incidence of infection, hospitalization and associated morbidities.The likelihood of hospitalization was 25.7% more in patients not in remission. Similarly, RA patients with co-morbidity were 22.8% more likely to be hospitalized than patient without co-morbidities. With reference to DMARD usage, patients on double DMARDs were 11.8% less likely and triple and four DMARD users were 1.2 and 2.2 times more likely to be hospitalized than single DMARD patients. The working status or income did not influence the likelihood of hospitalization. (data to be be published)

The study is touted as first of its kind underscoring the achievement of minimal disease activity and possible remission as the primary objective of RA management. Despite certain disadvantages of biologics, both minimal disease activity and possible remission are achieved by majority of the patients under treatment. Early referral and the use of biologics during early disease course have significantly improved the number of patients achieving remission in developing countries. The data, though large, is representative of the patient population from a single state. Such kind of studies are the need of the hour in the field of RA as they add to the evidence-based data required for formulating the best disease management guidelines.

References

1. Chandrashekara S, Shobha V, Dharmanand BG, Jois R, Kumar S, Mahendranath KM et al. Factors influencing remission in rheumatoid arthritis patients: results from Karnataka rheumatoid arthritis comorbidity (KRAC) study. Int J Rheum Dis. 2016 Jul 25. doi: 10.1111/1756-185X.12908.