Obesity in women and current smoking in men appear to be the strongest predictors of lack of remission in early rheumatoid arthritis (RA) within one year, according to new research presented June 13 at EULAR 2018, the annual meeting of the European League Against Rheumatism, in Amsterdam.

Even though early identification and aggressive treatment of RA improves outcomes, 46% of women and 38% of men with early RA who received guideline-based care did not reach remission within one year, the authors wrote in their abstract.

"There has never been a better time to have rheumatoid arthritis, as effective treatments are available that enable people to remain independent and continue to live full, meaningful lives. For example, an athlete in the 2018 Winter Olympics, snowboarder Spencer O'Brien, has rheumatoid arthritis," lead author Dr. Susan J. Bartlett of Johns Hopkins University in Baltimore and McGill University in Montreal, Canada, told Reuters Health.

"The goal of treatment is to bring RA inflammation under remission quickly. Unfortunately, evidence suggests that up to 40% of people with newly diagnosed RA continue to have active disease one year later," Dr. Bartlett, who presented the study, said by email.

"Our results suggest that lifestyle changes – smoking cessation in men and weight reduction in women – as well as optimizing methotrexate use may facilitate rapid reduction of inflammation, an essential goal of treatment in early rheumatoid arthritis," she wrote in a press release.

Dr. Bartlett and her colleagues compared predictors of persistent low, moderate, and high disease activity in 1,628 men and women in the first year of treatment for early RA.

Participants were enrolled in the Canadian Early Arthritis Cohort (CATCH) from 2007 to 2016 and were receiving guideline-based care. Overall, 72% were female, the average age was 55, the average number of comorbidities was 2, and the average symptom duration as 6 months.

Participants had active disease at baseline and were followed-up for at least 12 months. They underwent clinical assessments, questionnaires, and lab tests.

The authors used logistic regression with backward selection to identify predictors of failing to achieve remission, with a 28-joint disease activity score (DAS28) <2.6 by 12 months.

Conventional synthetic disease-modifying antirheumatic drugs

On multivariable analysis, obesity more than doubled the likelihood of not reaching remission in women. Other predictors were minority status, less education, as well as higher tender joint counts and fatigue scores at baseline. In men, current smoking was linked with a 3.5 greater likelihood of not reaching remission by 12 months. Other predictors included older age and greater pain.

Almost all patients in the study were initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and 75% were on methotrexate. Not using methotrexate increased the likelihood of lack of remission by 28% in women and by 45% in men.

"These results highlight the need to support physicians and empower patients to take advantage of the impact lifestyle changes can have on disease progression," Dr. Johannes W. Bijlsma, EULAR President, wrote in a press release.

"We consider it essential that recommendations reach all audiences – from rheumatologists, patients and patient organizations to healthcare professionals – in order to support all in understanding how to best manage the disease."

"A great deal of care and attention is placed on getting people started on effective treatments right away. Our data suggest that health behaviors also play an important role in determining how well treatment works and that different health behaviors contribute to suboptimal management in men and women," Dr. Bartlett said.

"Many are very expensive, too," she said. "It is important to not only understand who is at greater risk of not responding to treatment and what we might be able to do to improve outcomes. Lifestyle plays a very important role in improving disease control and RA outcomes. Also, RA affects three times as many women as men, so it's important to know that factors associated with suboptimal response to treatment differ in men and women."

"We don't know whether, if women lose weight or men stop smoking, this will improve the likelihood of quickly getting their RA under good control," Dr. Bartlett added. "These behaviors will definitely improve health, so there is no downside to adopting a healthier lifestyle. But whether this actually helps RA medications work more effectively has yet to be studied."