What Is Most Important in Rheumatoid Arthritis Treatment — Where You Are, Who You Are, or Where You Are Going?

The treatment of rheumatoid arthritis (RA) has been revolutionized by the expansion of conventional (c) and biologic (b) disease-modifying antirheumatic drug (DMARD) choices and the early aggressive treatment of RA to a target of remission or low disease activity, an approach endorsed in major RA treatment guidelines1,2. But if you search these guidelines for the words sex, gender, man, woman, men, women, male, and female, you will find these words appear only twice — once in a figure legend describing hepatitis B risk factors and the other in the title of a reference. While sex is not influencing RA treatment recommendations, is it influencing RA treatment choices in the real-world setting? In this issue of The Journal , Bergstra and colleagues asked whether sex differences exist in the selection of initial RA treatments and whether sex influences treatment response3. Bergstra and colleagues used data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology (METEOR) registry, an international observational registry that records data from routine clinical practice — truly a real-“world” study. The authors selected over 5000 patients with RA diagnosed in the last 3 months who were not in Disease Activity Score (DAS) remission and were initiating their first DMARD. The authors evaluated initial treatment patterns: both general approaches (e.g., monotherapy vs combination therapy ± glucocorticoids) and specific DMARD within these general approaches. Subsequently, they assessed the influence of sex on treatment response, measured by time to switching DMARD and trajectories of the DAS and Health Assessment Questionnaire (HAQ) scores. They found that general approaches in initial RA management were identical between the sexes, but they detected differences in the choice of specific DMARD. Men were more likely than women to start a regimen that contained methotrexate (MTX) or … Address correspondence to Dr. B.R. England, 983025 Nebraska Medical Center, Omaha, Nebraska 68198-3025, USA.

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