July 8, 2019
People who develop rheumatoid arthritis (RA) as older adults, benefit from early and sustained use of a drug called Methotrexate (MTX), a treatment considered by many rheumatologists to be a first line of defense in managing the disease. Now, a new study led by Jessica Widdifield, an assistant professor at the Institute of Health Policy Management and Evaluation, has found that patients who have access to MTX earlier in their diagnosis, also reduce their risk of cardiovascular events associated with the disease.
“Rheumatoid arthritis is an inflammatory disease, and patients who develop the condition at an older age have a higher disease activity and inflammation in their joints,” says Widdifield who is also a scientist at Sunnybrook Research Institute and ICES. “This type of chronic systemic inflammation has been linked to atherogenesis, a disease of the arteries, but MTX may also influence this type of inflammation throughout the body, reducing a patient’s cardiovascular risk.”
While MTX as a drug has been vetted for safety and efficacy, it is also a chemotherapeutic agent and an immunosuppressive drug, which means that some family physicians just aren’t comfortable prescribing it. Early access to treatment for rheumatoid arthritis is dependent on a patient’s ability to see a rheumatologist, creating a barrier for older adults that can delay the effectiveness of the drug.
“There are many factors that delay access to treatment, one of which is a shortage of rheumatologists, which leads to longer wait times,” says Widdifield. “Another is that patients might delay presenting to primary care physicians thinking that they are suffering with just arthritis or symptoms of getting older.”
Widdifield also notes that primary care physicians may not always recognize signs and symptoms of rheumatoid arthritis and the urgency of a referral to a rheumatologist. Further delays in treatment may also result from a rheumatologist opting to use another form of treatment other than MTX.
Each of these barriers can have a negative impact on the ability of MTX to diminish long-term risks including cardiovascular events and even delay helping patients end up remission. According to the study, within the first year of diagnosis, patients who were treated with MTX experienced a lower rate of cardiovascular events, and those that were given the drug continuously and assessed in the last 12 months, reduced their risk by 20%.
Widdifield’s study is the first of its kind to examine the evidence around the effect of timing of MTX initiation in relation to long-term outcomes. With evidence already in place showing that early MTX treatment helped patients end up in remission from the disease, Widdifield felt it was imperative to also assess whether early treatment also reduced cardiovascular risks.
“Our evidence supports the recommendation that rheumatoid arthritis patients should receive methotrexate treatment early and continue to receive it in order to control the disease and reduce their risk of a cardiovascular event,” says Widdifield.
Her study also demonstrates the importance of rheumatologists in providing timely care. In Canada, Widdifield points out that the supply of rheumatologists has not kept up with the needs of our growing and aging population, increasing the burden of symptoms and risks on patients with rheumatoid arthritis.
“We have made great strides in improving care and outcomes for Canadians with rheumatoid arthritis,” says Widdifield, “but future patients may not have the same experience if we don’t also address the impending shortage and maldistribution of rheumatologists across the country.”