Practice Update: Conference Series - EULAR Congress 2017

Over the past 15 years, knee and hip replacements and excess risk of cardiovascular events have dropped in patients with rheumatoid arthritis

Results of two studies have demonstrated that the incidence of total knee replacements carried out on patients with rheumatoid arthritis has begun to drop since the introduction of biological disease-modifying antirheumatic drugs (DMARDs) to Danish national treatment guidelines. Excess risk of cardiovascular disease has also

declined in the population at large. T hese conclusions were based on results of an interrupted time series analysis using nationwide Danish healthcare registries and a meta-analysis. Total knee and hip replacement Lene Dreyer, MD, of the Centre for Rheumatology and Spine Diseases, Gentofte in Copenhagen, Denmark, explained that Danish national guide- lines recommending biological DMARD treatment for rheumatoid arthritis were introduced in Denmark in 2002. In the present analysis, trends in the pre-biological DMARD guideline era (1996–2002) were compared with those in the biological DMARD period (2003–2016). Five-year age and sex-standardised inci- dence rates of total hip and total knee replacement were calculated for 30,868 patients with rheumatoid arthritis who were diagnosed biannually between 1996 and 2011, vs 301,527 matched controls who did not suffer from rheumatoid arthritis. Prior to 2002, when the updated guidance on biological DMARDs for rheumatoid arthritis was introduced, the incidence of total knee replacement had been increasing among patients with rheuma- toid arthritis. In a general population of individuals matched in terms of age, sex and locale of residence, the incidence of total knee replacement continued to rise from 1996–2016. In contrast, the incidence of total knee replacement in patients with rheumatoid arthritis began to drop after the intro- duction of biological DMARDs in Danish national treatment guidelines. The incidence of total hip replacements has also maintained a steady rise in the matched population. Among patients with rheumatoid arthritis, however, apart from a surprising increase in 2003, the

incidence of total hip replacement has trended downward both before and after the guidance was introduced. Data are conflicted regarding the possi- ble impact of more aggressive treatment, including biological DMARDs, on the need for knee and hip replacements in patients with rheumatoid arthritis. With a baseline incidence rate of 5.87 total knee replacements per 1000 per- son-years in patients with rheumatoid arthritis, based on biannual data, before 2002, the incidence of total knee replace- ment had been increasing at a rate of +0.19 per year. After 2003, the downward trend has been equivalent to a –0.20 reduction in incidence per year. With a baseline incidence rate of 8.72 total hip replacements per 1000 person years in patient with rheumatoid arthritis, based on biannual data, the downward trend was equivalent to a –0.38 reduction in incidence per year both before 2002 and after 2003. In 2003, the annual incidence of total hip replacement rose temporarily by +2.23. Dr Dreyer said, “Our findings showed a clear downward trend in these two oper- ations in Danish patients with rheumatoid arthritis since the addition of biological DMARDs to treatment protocols.” “Also,” he added, “the overall pattern of our findings is in line with those recently reported from England and Wales. In addition, more widespread use of con- ventional DMARDs and the treat-to-target strategy may have contributed to this pos- itive development.” Excess risk of cardiovascular events The excess risk of cardiovascular events in patients with rheumatoid arthritis relative to the general population has decreased since the year 2000.

Dr Lene Dreyer

Dr Gaujoux-Viala

Cécile Gaujoux-Viala, MD, of the University of Montpellier and the Nîmes University Hospital in France, explained that compared with the general popu- lation, patients with rheumatoid arthritis are known to be at increased risk of car- diovascular disease or events, including stroke, myocardial infarction, congestive heart failure and cardiovascular mortality. Dr Gaujoux-Viala and colleagues set out to assess the excess risk of cardiovascular events in patients with rheumatoid arthritis vs the general population before and after the 2000s. They performed a detailed literature search that included PubMed and Cochrane Library until March 2016. Of 5714 screened references, 28 eligible observational studies provided data on cardiovascular events (stroke, myocar- dial infarction, congestive heart failure, cardiovascular mortality) in patients with rheumatoid arthritis and in a control group. The meta-analysis of relative risk con- cerning patients with rheumatoid arthritis in relation to the control group was per- formed for each cardiovascular event and for the periods before and after the 2000s. For studies published before 2000, a highly significant increase in the risk of all four cardiovascular events was observed in patients with rheumatoid arthritis vs controls as follows: ƒ ƒ Stroke : relative risk 1.12, [95% CI 1.04– 1.21, P = 0.002] ƒ ƒ Congestive heart failure : relative risk 1.25 [95% CI 1.14–1.37, P < 0.00001] ƒ ƒ Cardiovascular mortality : relative risk 1.21 [95% CI 1.15–1.26, P < 0.00001] ƒ ƒ Myocardial infarction : relative risk 1.32 [95% CI1.24–1.41, P < 0.00001]

PRACTICEUPDATE CONFERENCE SERIES • EULAR CONGRESS 2017 10