Title: Quality of Life in Rheumatoid Arthritis patients taking combination DMARDs
Authors: Paramjeet Singh, Mehar Bano, Suyash Bharat, Bhavana Srivastava, Arun Joshi
DOI: https://dx.doi.org/10.18535/jmscr/v5i4.193
Abstract
Objective: To assess the QOL of RA patients taking non biological combination DMARDs
Material & Methods
Study Design: Open Label Study
Treatment naïve or chronic cases of RA in age group of 18-60 years of both sex with RA duration >= 6 months and Disease Activity Score (DAS28) >3.2 were included. 131 patients were taken and categorized in 2 study groups for taking of combination of DMARDs. Group-1 patients (n=68) were taking/given. Methotrexate weekly with hydroxychloroquine oral daily. Group-2 patients (n=63) were taking/given Methotrexate weekly as in group-1 patients with tablet salfasalazine oral daily. The patients who were already on these combination DMARDs were also included.
Observations: The mean duration of disease was 4 years in both the groups. On comparing the baseline and end study values, there was significant improvement in all the domains of domains of WHO-QOL BREFT within the groups.
There was significant improvement in quality of life in all the domains of WHOQOL BREF within the groups. However, when comparing domain score between treatment groups, both before and after the treatment, the difference is statistically not significant, except in environmental domain score at the end of the study. Also, within the group, the mean scores of various domains of QOL is significantly increasing at the end of th 5th follow up with insignificant differences seen for social domain in group-1 only.
Conclusion: The study recommends that use of conventional DMARDs in different combinations help in improvement of QOL of RA patients and therefore these drugs should be started early in the course of the disease
Keywords– Rhueumatoid Arthritis (RA), Disease Modifying Anti-Rheumatic Drugs (DMARDs), World Health Organization- Quality of Life (WHO-QOL), Disease Activity Score (DAS).
References
1. Scott D, Coulton B, Symmons D, Popert A. Long-term outcome of treating Rheum-atoid Arthritis: results after 20 years. The Lancet. 1987; 329(8542):1108-1111.
2. Demoruelle MK, Deane KD. Treatment Strategies in Early Rheumatoid Arthritis and Prevention of Rheumatoid Arthritis. Current rheumatology reports. 2012;14(5):472-480.
3. Raza K, Buckley C, Salmon M, Buckley C. Treating very early rheumatoid arthritis. Best Practice & Research Clinical Rheumatology. 2006;20(5):849-863.
4. Boers M. Understanding the window of opportunity concept in early rheumatoid arthritis. Arthritis & Rheumatism. 2003;48(7):1771-1774.
5. Moreland LW, Russell AS, Paulus HE. Management of rheumatoid arthritis: the historical context. J Rheumatol 2001; 28:1431–52.
6. Wolfe F, Cush JJ, O’Dell JR, Kavanaugh A, Kremer JM, Lane NE, et al. Consensus recommendations for the assessment and treatment of rheumatoid arthritis. J Rheumatol 2001; 28:1423–30.
7. Smolen J, Aletaha D, Machold K. Therapeutic strategies in early rheumatoid arthritis. Best Practice & Research Clinical Rheumatology. 2005;19(1):163-177.
8. Van der Heide A, Jacobs JW, Bijlsma JW, Heurkens AH, van Booma-Frankfort C, Van der Veen MJ, et al. The effectiveness of early treatment with ‘‘second-line’’ antirheumatic drugs. A randomized, controlled trial. Ann Intern Med 1996; 124:699–707.
9. Capell H, Madhok R, Porter D, Munro R, McInnes I, Hunter J et al. Combination therapy with sulfasalazine and methotrexate is more effective than either drug alone in patients with rheumatoid arthritis with a suboptimal response to sulfasalazine: results from the double-blind placebo-controlled MASCOT study. Annals of the Rheumatic Diseases. 2006;66(2):235-241
10. Landewe RB Boers M, Verhoeven A, Westhovens R, van de Laar M, Markusse H et al. COBRA combination therapy in patients with early rheumatoid arthritis: Long-term structural benefits of a brief intervention. Arthritis & Rheumatism. 2002;46(2):347-356.
11. Wilske KR, Healey LA. Remodeling the pyramid: a concept whose time has come. J Rheumatol 1989; 16:565–7.
12. Kirwan JR, Bijlsma JW, Boers M, Shea BJ. Effects of glucocorticoids on radiological progression in rheumatoid arthritis. Cochrane Database Syst Rev: 2007 Jan 24;(1)
13. O'Dell J, Leff R, Paulsen G, Haire C, Mallek J, Eckhoff P et al. Treatment of rheumatoid arthritis with methotrexate and hydroxychloroquine, methotrexate and sulfasalazine, or a combination of the three medications: Results of a two-year, randomized, double-blind, placebo-controlled trial. Arthritis & Rheumatism. 2002; 46(5):1164-1170.
14. Keystone E, Smolen J, van Riel P. Developing an effective treatment algorithm for rheumatoid arthritis. Rheumatology. 2012; 51(suppl 5):v48-v54
15. S. Saxena et al. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India The National Medical Journal of India VOL. 11, No.4, 1998.
16. Fransen J, van Riel P. The Disease Activity Score and the EULAR Response Criteria. Rheumatic Disease Clinics of North America. 2009;35(4):745-757.
17. Gabriel S, Crowson C, Kremers H, Doran M, Turesson C, O'Fallon W et al. Survival in rheumatoid arthritis: A population-based analysis of trends over 40 years. Arthritis & Rheumatism.2003;48(1):54-58.
18. Kvien TK, Scherer HU and Burmester GR (2009). Rheumatoid arthritis. EULAR Compendium on Rheumatic Diseases, BMJ Publishing Group and European League Against Rheumatism: 61-80.
19. Kaipiainen O, Seppänen O .Chronic arthritis in Finland.2002 Duodecim 116: 1445-51.
20. Neovius M, Simard J, Askling J. Nationwide prevalence of rheumatoid arthritis and penetration of disease-modifying drugs in Sweden. Annals of the Rheumatic Diseases. 2010;70(4):624-629.
21. Aletaha D. The rheumatoid arthritis patient in the clinic: comparing more than 1300 consecutive DMARD courses. Rheumatology. 2002;41(12):1367-1374.
22. Singh N. R, Wangjam K. Treatment of Rheumatoid Arthritis with Combination of Disease Modifying Anti-Rheumatic Drugs: A Three-year follow-up study. IJPMR. 2001 April ; 12.
23. E. H. S. Choy, C. Smith, C. J. Dore´ and D. L. Scott, A meta-analysis of the effi-cacy and toxicity of combining disease-modifying anti-rheumatic drugs in rheum-atoid arthritis based on patient withdrawal. Rheumatology 2005;44:1414–1421 doi:10.1093/rheumatology/kei031Advance Access publication 19 July 2005
24. Marks J, Power B. Is Chloroquine obsolete in treatment of Rheumatic Disease? The Lancet. 1979; 313(8112):371-373.
25. Finbloom DS, Silver K, Newsom DA, Gunkel R .Comparison of Hydroxychloroquine and chloroquine use and development of retinal toxicity. J Rheumatol, 1985 ; 12:692–694.
26. Malaviya AN, Kapoor SK, Singh RR, Kumar A, Pande I. Prevalence of rheumatoid arthritis in the adult Indian population. Rheumatol Int. 1993; 13(4): 131-4.
27. Paul B, Thachil E, Jayachandran N, Radhakrishnan S. Clinical efficacy and adverse effects of weekly single dose leflunomide in refractory rheumatoid arthritis. Indian Journal of Rheumatology. 2007;2(1):3-7.
28. Kapral T, Stamm T, Machold KP, Montag K, Smolen JS, Aletaha D. Methotrexate in rheumatoid arthritis is frequently effective, even if re-employed after a previous failure. Arthritis Research & Therapy. 2006; 8(2):R46.
29. Buhroo A M, Baba A N. Adverse Effects of Low-Dose Methotrexate in Patients with Rheumatoid Arthritis. IJPMR. 2006 October ; 17(2)
30. Gawde S. Drug Utilization Pattern and Cost Analysis in Rheumatoid Arthritis Patients - A Cross-Sectional Study in Tertiary Care Hospital, Mumbai. BJPR. 2013;3(1):37-45
31. Shah A, St. Clair E. Rheumatoid Arthritis. In: Longo D, Kasper D, Jameson J, Fauci A, Hauser S, Loscalzo J, ed. by. Harrison's Principles of Internal Medicine. 18th ed. United States of America: McGraw-Hill Companies, Inc; 2012.
32. Kuriya B, Cheng C, Chen H, Bykerk V. Validation of a prediction rule for development of rheumatoid arthritis in patients with early undifferentiated arthritis. Annals of the Rheumatic Diseases. 2008;68(9):1482-1485.
33. Boutry N, Carmo C, Flipo R, Cotten A. Early rheumatoid arthritis and its differentiation from other joint abnormalities. European Journal of Radiology. 2009;71(2):217-224.
34. O'Dell J, Haire C, Erikson N, Drymalski W, Palmer W, Eckhoff P et al. Treatment of Rheumatoid Arthritis with Methotrexate Alone, Sulfasalazine and Hydroxychl-oroquine, or a Combination of All Three Medications. New England Journal of Medicine. 1996;334(20):1287-1291
35. Too C, Rönnelid J, Yusoff Y, Dhaliwal J, Jinah N, Yahya A et al. Increased IgG Rheumatoid Factor-Positivity in the Asian Rheumatoid Arthritis Patients Irrespective of Ethnicity. Open Journal of Rheumat-ology and Autoimmune Diseases. 2014;04(01):43-51.
36. Ghosh B, Halder S, Ghosh A, Dhar S. Early rheumatoid arthritis: clinical and therapeutic evaluation in a tertiary care centre in India. Indian Journal of Rheumatology. 2008;3(2):48-51
37. Möttönen T, Hannonen P, Korpela M, Nissilä M, Kautiainen H, Ilonen J et al. Delay to institution of therapy and induction of remission using single-drug or combination-disease-modifying antirheumatic drug therapy in early rheumatoid arthritis. Arthritis & Rheumatism. 2002;46(4):894-898
38. Spies C, Bijlsma J, Burmester G, Buttgereit F. Pharmacology of glucocorticoids in rheumatoid arthritis. Current Opinion in Pharmacology. 2010;10(3):302-307
39. Kavanaugh A, Wells AF. Benefits and risks of low-dose glucocorticoid treatment in the patient with rheumatoid arthritis. Rheumatology (Oxford, England). 2014;53(10):1742-1751. doi:10.1093/rheumatology/keu135.
40. Gorter S, Bijlsma J, Cutolo M, Gomez-Reino J, Kouloumas M, Smolen J et al. Current evidence for the management of rheumatoid arthritis with glucocorticoids: a systematic literature review informing the EULAR recommendations for the management of rheumatoid arthritis. Annals of the Rheumatic Diseases. 2010;69(6):1010-1014.
41. Habib G, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol. 2010;29(4):347-356.
42. Hetland M, Stengaard-Pedersen K, Junker P, Lottenburger T, Hansen I, Andersen L et al. Aggressive combination therapy with intra-articular glucocorticoid injections and conventional disease-modifying anti-rheumatic drugs in early rheumatoid arthritis: second-year clinical and radiographic results from the CIMESTRA study. Annals of the Rheumatic Diseases. 2008;67(6):815-822.
43. Crofford LJ. Use of NSAIDs in treating patients with arthritis. Arthritis Research & Therapy. 2013; 15(Suppl 3):S2
44. Hunter JA, Parnham MJ, Balaguer XG. Aceclofenac in rheumatoid arthritis: a useful and novel anti-inflammatory. Clin Rheumatol. 1996 Jul;15(4):329-34.
45. O'Carroll R, Cossar J, Couston M, Hayes P. Sensitivity to Change Following Liver Transplantation: A Comparison of Three Instruments that Measure Quality of Life. Journal of Health Psychology. 2000; 5(1):69-74.
46. A Barman, A Chatterjee, KM Das, PK Mandal, A Ghosh, A Ballav . Fatigue, Physical Function and Quality of Life in Relation to Disease Activity in Established Rheumatoid Arthritis. IJPMR 2010; 21 (1): 15-21
47. Taylor W, Myers J, Simpson R, McPherson K, Weatherall M. Quality of life of people with rheumatoid arthritis as measured by the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF): Score distributions and psychometric properties. Arthritis Care & Research. 2004; 51(3):350-357.