Disappointing longterm results with disease modifying antirheumatic drugs.A practice based study

Objective, To evaluate the longterm effectiveness of disease modifying anti rheumatic drugs (DMARD) in an inception cohort of patients with rheumatoid arthritis (RA) seen by rheumatologists. Methods. We performed a retrospective audit of the records of patients with onset of RA between January 1985 and June 1994. Charts were reviewed from the time of diagnosis to the last consult. Survival analysis was performed using Kaplan-Meier and Cox proportional hazard regression to adjust for pot ential confounders. Results. A total of 2296 DMARD therapies were analyzed. Roughly half were s tarted within 2 years of disease onset. By 16 months, 50% of the DMARD ther apy courses had been discontinued, and after 4.5 years 75% had been discont inued. Over all, methotrexate (MTX) had the highest probability of continua tion. After roughly 3 years 50% of patients were still receiving MTX, compa red to one-third of patients who received antimalarials or intramuscular go ld, 30% D-penicillamine, 25% sulfasalazine, and 18% oral gold. After 6 year s, when considering all DMARD together, only 20% of the therapies had not b een discontinued, with no substantial differences between drugs. Toxicity f rom gold compounds occurred within the first 18 months of therapy and stabi lized thereafter. For MTX, withdrawals due to toxicity continued throughout therapy. Conclusion. This is the largest observational study examining the longterm termination rates of DMARD in patients followed from the time of their init ial consult. Our results confirm previous reports of short therapeutic time s, even for patients treated early in the course of their disease. MTX appe ars to be the best drug within the first 5 years of disease. These differen ces, however, decrease in the longer term. It is unclear whether the result s observed for MTX within the first years of therapy translate to better he alth status in the longer term when compared to other DMARD.