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High multibiomarker disease activity score linked to biologic, JAK inhibitor addition, switching in RA
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A high multibiomarker disease activity — or MBDA — test score is associated with biologic and JAK inhibitor treatment addition or switching among patients with rheumatoid arthritis, according to data published in the Journal of Rheumatology.
“The MBDA test, a prospectively validated measure of RA disease activity, has been shown to predict radiographic outcomes,” Jeffrey R. Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, and colleagues wrote. “Unlike [C-reactive protein] or [erythrocyte sedimentation rate], the MBDA test provides cutpoints that classify disease activity in RA as low (< 30), moderate (30-44), or high (> 44). However, the clinical utility of MBDA testing for patients with RA has not been studied in routine practice in the U.S.”
To analyze the effectiveness of the multibiomarker disease activity test for RA management in routine care, Curtis and colleagues studied Medicare data from 2011 to 2015 and linked each patient with RA to their test result. In total, the researchers identified more than 75,000 patients with RA, with fee-for-service Medicare coverage, who had at least one multibiomarker disease activity test. A total of 60,596 patients with RA who had such testing were included in the analysis.
The researchers analyzed the initiation of biologic or JAK inhibitor treatment in the 6 months following multibiomarker disease activity testing, and used multivariable adjustment to evaluate the likelihood of adding or switching. In addition, they studied the value of a lack of test score improvement in predicting future RA medication failure — defined by the need to change medications again — among patients with high test scores who added a new therapy and were later retested.
Among 33,728 patients with RA and multibiomarker disease activity testing included in the analysis, the proportion of those who added or switched biologics or a JAK inhibitor — and were not already taking a biologic or JAK inhibitor — was 9% in those with a low test score, 11.8% in those with a moderate score and 19.7% in those with a high score (P < .0001). In addition, among the 26,868 patients with RA included in the analysis who were already taking biologics or a JAK inhibitor, these proportions were 5.2% among those with a low score, 8.3% for moderate scores and 13.5% for high scores (P < .0001).
Following a multivariable adjustment, the likelihood of switching was 1.51-fold greater (95% CI, 1.35-1.69) for patients with moderate multibiomarker disease activity scores compared to those with low scores. Among patients with high scores, the likelihood was 2.62-fold greater (95% CI, 2.26-3.05) compared to those with low scores. Patients with high scores who later added a biologic or JAK inhibitor and were retested were associated with a lack of improvement in test score category, as well as a likelihood of future RA treatment failure (OR = 1.61; 95% CI, 1.27-2.03).
“Even for patients who might seem to be in low disease activity based on clinical assessment, a high MBDA score has been shown to predict increased risk for radiographic progression,” Curtis and colleagues wrote. “As a necessary first step to evaluating patients with RA and facilitating a treat to-target management style, quantitative clinical disease activity assessment is key, yet remains underused in the U.S. The MBDA test can be used to complement clinical assessment and can categorize patients as being in low, moderate, or high disease activity; something that ESR, CRP, or advanced joint imaging does not allow.” – by Jason Laday
Disclosure: Curtis reports support from the NIH and the Patient-Centered Outcome Research Institute, as well as research grants and/or consulting fees from Amgen, BMS, Corrona, Janssen, Myriad Genetics, Pfizer and UCB. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Joseph E. Huffstutter, MD
Optimal management of rheumatoid arthritis is challenging due to a variety of factors. Early diagnosis maybe difficult due to heterogeneous presentations, lack of specificity and sensitivity of laboratory testing, referral patterns, etc. Once diagnosed, the course is variable, unpredictable and difficult to measure due to comorbid conditions, patient subjectivity of pain evaluation, and laboratory results. Management of a patient’s response to therapy is critical to achieving optimal disease control.
The article by Curtis and colleagues describes the utilization of a Multibiomarker Disease Activity Test (MBDA or Vectra DA) by providers nationwide in a Medicare population from 2011 through 2015. The researchers describe a growing minority of providers ordering the test. The objectivity of the score adds value to the care of the patient with RA who has multiple illnesses that may also cause pain, thus interfering with many of the scoring methods of disease activity. Although not helpful in diagnosing or predicting a response to a particular therapy, it does predict radiographic progression better than other disease measures.
The article demonstrates how repeat testing may allow providers to move quickly to adjust therapy to control disease. Recent modifications of the Vectra DA scoring system to adjust for sex, age and body mass index further refine the accuracy of the score which should make it more valuable as an objective disease measure.
As a clinician, I use the score to monitor disease, predict progression and as a referee when there is discordance with my clinical opinion and the patient’s assessment of disease activity. Therefore, patients whose symptoms are not related to active RA can be spared unnecessary medications, while patients with inadequate disease control may be more accepting of needed therapies to lower disease activity and prevent progression. I think this test may help fine-tune therapy for a number of RA patients.
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