Uncertainty on Pre-Clinical RA – Rheumatologist Survey Results Save

Jack Cush, MD

Sep 27, 2023 12:47 pm

In June 2023, RheumNow surveyed US and non-US rheumatologists (Rheums) about how they consider and manage pre-clinical rheumatoid arthritis (RA) in their practice.

In the last few years there have been numerous well designed and appropriately powered randomized clinical trials of pre-clinical RA patients receiving either a placebo or active intervention. Such trials of common or targeted therapies studies named PRAIRI (rituximab), TREAT-EARLIER (methotrexate), STOP-RA (hydroxychloroquine), ARIAA and APIPPRA (both with abatacept).

With a multiplicity of trials, the question arises whether rheumatologists are well informed and clear about their treatment choices in patients presenting as “pre-clinical RA” (defined as chronic polyarthralgia, without synovitis, often seropositive or possibly a first-degree relative to an RA patient).

A total of 247 responses were received from verified rheumatologists; 48% from the USA with a total of 53 countries responding worldwide.

Below are the rheumatologist’s responses to six survey questions on pre-clinical RA, along with the interpretations and takeaway teaching points to each question.

Question 1. What do you need to better manage pre-clinical (at-risk) RA?
Choices	Responses	Commentary
Optimal testing	21%	Half of Rheums are unclear on who to treat aggressively with DMARDs or biologics; 13% are unclear about symptomatic treatment and over one-third would like to know how to better diagnose these patients (with criteria or testing). The results were equivalent between US and non-US rheumatologists. These results indicated at least a moderate degree of uncertainty when rheums are confronted by a pre-clinical RA patient.
Criteria	16%
Who to treat aggressively	50%
Who to treat symptomatically	13%

Question 2. How many new polyarthralgia, pre-clinical RA patients do you see per month?
Choices	Responses	Commentary
1-4	57%	A majority of Rheumatologists see only a few pre-clinical RA patients or so few as to be unsure. Hence, the uncertainty noted in question one is rooted in these patients being a low frequency subset of those referred or encountered. Moreover, the epidemiology of pre-clinical RA is unknown. Identifying and referring pre-clinical RA patients who may benefit from effective therapy, will be challenging.
5 or more	24%
Unsure	13%
Zero	6%

Question 3. Is there sufficient evidence on pre-clinical RA for you to initiate specific treatment?
Choices	Responses	Commentary
No	63%	Despite the number of recent trials addressing pre-clinical RA, Rheums are generally unaware of existing data that might guide their treatment choices. This is more of an educational unmet need than data deficit. The results were equivalent between US and non-US rheumatologists.
Yes	18%
Unsure	19%

Question 4. Which do you rely on to diagnose pre-clinical RA?
Choices	Responses	Commentary
RF or CCP	70%	As the pre-clinical RA designation hinges on the lack of synovitis, Rheums emphasize seropositivity as the basis for this diagnosis; and give little import to either family history or acute phase reactant results. It may be that pre-clinical RA should be renamed “seropositive pre-clinical RA”.
Number of tender joints	16%
ESR or CRP	9%
Family history	5%

Question 5. How do you manage patients with pre-clinical RA in your practice?
Choices	Responses	Commentary
Observe/retest	27%	Conservatism reigns over the rheumatologist approach to pre-clinical RA management as more than three-quarters prefer to observe/wait or only provide symptomatic therapy. Only 9% will use a DMARD or biologic on these patients. This is the one survey question where US Rheums differed from the rest of the world. US Rheums were more conservative with 59% giving symptomatic therapy, 24% observing and testing and only 6.8% were willing to prescribe a DMARD or biologic agent.
Symptom management	50%
Corticosteroids	15%
DMARD or biologic	9%

Question 6. Which treatment target would you prefer in a pre-clinical RA patient?
Choices	Responses	Commentary
TNF alpha	4%	As above, symptomatic treatment is the primary response by Rheums worldwide and in the US. Biologic choices were unpopular.
T cells	5%
B cells	9%
Symptoms only	50%
Nonspecific immunosuppression	32%