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Delay in initiation of DMARD or anti-inflammatory therapy in patients newly diagnosed with rheumatoid arthritis: An analysis of United States Military Health System TRICARE beneficiaries

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Kimsey L1, Weissman JS2, Patel A3, Drew A4, Koehlmoos T3, Sparks JA2. Semin Arthritis Rheum. 2018 Jul 18. pii: S0049-0172(18)30305-6. doi: 10.1016/j.semarthrit.2018.07.003. [Epub ahead of print]

Abstract

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1 Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, United States. Electronic address: lkimsey@georgiasouthern.edu.

2 Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.

3 Uniformed Services University of the Health Sciences, Bethesda, MD, United States.

4 Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, United States.

Abstract

OBJECTIVE: To investigate factors associated with delay in initiation of initial disease-modifying antirheumatic drug (DMARD) in patients newly diagnosed with rheumatoid arthritis (RA).

METHODS: We performed a retrospective cohort descriptive study using administrative data from the US military's TRICARE program (2007-2012). We identified incident RA cases using billing codes and initial DMARD receipt using prescription fill date. We quantified the time between RA presentation and initial DMARD receipt, evaluated temporal changes in delay over the study period, and investigated predictors of treatment delay (> 90 days) using logistic regression.

RESULTS: We identified 16,680 patients with incident RA that were prescribed DMARDs and mean age was 47.2 (SD 13.5) years. The mean time from initial RA presentation to first DMARD prescription receipt was 125.3 days (SD 175.4). Over one-third (35.6%) of incident RA patients initiated DMARD > 90 days after presentation. There was less treatment delay in later years of the study (mean days to DMARD of 144.7 days in 2007; 109.7 days in 2012). Patients prescribed opioids had mean time to DMARD of 212.8 days (SD 207.4) compared to mean of 77.3 days (SD 132.3) for those who did not use opioids (p < 0.0001). Patients prescribed opioids between RA presentation and initial DMARD receipt were more likely to have delay in initial DMARD (OR 4.07, 95% CI: 3.78-4.37).

CONCLUSION: In this large US nationwide study, delays in initial DMARD receipt for incident RA were common but time to treatment improved in recent years. While further analysis using clinical data is warranted, these findings suggest that limiting opioid use in patients newly presenting with RA may decrease delay in initiating DMARDs.