Impact of physicians' adherence to treat-to-target strategy on outcomes in early rheumatoid arthritis in the NEO-RACo trial

Objectives: It is well recognized that medication adherence of rheumatoid arthritis (RA) patients is often poor. As less attention has been paid to physicians' adherence to targeted treatment, we aimed to investigate how it affects outcomes in aggressively treated early RA patients.Method: In the new Finnish RA Combination Therapy (NEO-RACo) trial, 99 patients with early active RA were treated, targeting remission, with a combination of methotrexate, sulfasalazine, hydroxychloroquine, and low-dose prednisolone for 2years, and randomized to receive infliximab or placebo for the initial 6months. After 2years, therapy was unrestricted while remission was still targeted. Patients were divided into tertiles by physicians' adherence to treat-to-target, which was evaluated with a scoring system during the initial 2years. After 5years of follow-up, the between-tertile differences in remission rates, 28-joint Disease Activity Score (DAS28) levels, radiological changes, cumulative days off work, and the use of anti-rheumatic medication were assessed.Results: Follow-up data were available for 93 patients. Physicians' good adherence was associated with improved remission rates at 2-4years and lower DAS28 levels throughout the follow-up. In a multivariable model, physicians' adherence was the most important predictor of remission at 3months and 2years (p<0.001 for both). Between 2 and 5years, biologics were used more often in the tertile of low adherence compared with the other two groups (p=0.024). No significant differences were observed in radiological progression and cumulative days off work.Conclusions: Physicians' good adherence is associated with improved remission rates and lesser use of biologics in early RA.