patient care perspectives

Gender-Based Differences in Rheumatoid Arthritis Remissions

by James O’Dell, MD, MACR, MACP

Overview

There are well-known differences with respect to prevalence, as well as – to a lesser extent – disease course and treatment outcomes, between male patients with rheumatoid arthritis (RA) and female patients with RA. Our featured expert discusses the impact of one’s sex on RA remissions and how these differences between men and women can inform management decisions.

Expert Commentary

James O’Dell, MD, MACR, MACP

Stokes Shackleford Distinguished Professor
Chief, Division of Rheumatology and Vice Chair for Education, Department of Internal Medicine
Director, Internal Medicine Residency Program
University of Nebraska Medical Center
Founder and Director, Rheumatoid Arthritis Investigational Network
Omaha, NE

“Women are more likely to develop RA and have more severe disease than men, and men often have a greater treatment response.”

James O’Dell, MD, MACR, MACP

One’s gender has a well-recognized impact on the prevalence and, to a lesser extent, disease course and treatment outcome in patients with RA. Women are more likely to develop RA and have more severe disease than men, and men often have a greater treatment response, as demonstrated in nearly every well-powered, well-designed clinical trial, including the Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial (NCT00259610) and the Rheumatoid Arthritis: Comparison of Active Therapies in Patients With Active Disease Despite Methotrexate Therapy (RACAT) trial (NCT00405275). However, despite these differences, both men and women with RA experience improvements in disease activity when they receive appropriate treatment, and there is not a differential response across therapies. In other words, I will use the same drugs in a given clinical scenario, regardless of the patient’s sex. While I know that “X” percent of men will respond to a particular medication and that a slightly lower percentage of women will respond to that same medication, it will not change my treatment of these patients. This allows me to reassure my patients about their prospects for a favorable outcome with treatment. It is unusual for a patient to not do well, regardless of sex, if he or she adheres to his or her medication regimen.

Nevertheless, there are some considerations regarding age and gender. For example, I would be much less concerned with a 65-year-old man taking corticosteroids than I would for a 65-year-old woman because the risk of osteoporosis is more distant for the man than it is for the woman. There are also some gender differences with respect to disease processes, such as significantly more lung disease in men, but we do not yet know how differences in parameters could translate into the selection of therapies for various patient groups. Thus, the treatment of RA, to a large degree, remains an art form. While guidelines can be useful in the management of RA, the role of clinical judgment remains significant because there are not studies that directly apply to every clinical situation. Protocolized-driven therapy is good, to a point, but it breaks down faster in RA than in other disease states. You have to weigh the pros and cons of a particular therapy for each individual situation, but I have never seen a patient with RA whom I could not help.

References

Aldridge J, Pandya JM, Meurs L, et al. Sex-based differences in association between circulating T cell subsets and disease activity in untreated early rheumatoid arthritis patients. Arthritis Res Ther. 2018;20(1):150.

Forslind K, Hafström I, Ahlmén M, Svensson B, BARFOT Study Group. Sex: a major predictor of remission in early rheumatoid arthritis? Ann Rheum Dis. 2007;66(1):46-52.

Hallert E, Björk M, Dahlström O, Skogh T, Thyberg I. Disease activity and disability in women and men with early rheumatoid arthritis (RA): an 8-year followup of a Swedish early RA project. Arthritis Care Res (Hoboken). 2012;64(8):1101-1107.

Jawaheer D, Messing S, Reed G, et al. Significance of sex in achieving sustained remission in the Consortium of Rheumatology Researchers of North America (CORRONA) cohort of rheumatoid arthritis patients. Arthritis Care Res (Hoboken). 2012;64(12):1811-1818.

Johansson L, Ärlestig L, Kokkonen H, Brink M, Rantapää-Dahlqvist S. An increased concentration of receptor activator of nuclear factor kappa-B ligand pre-dates the onset of rheumatoid arthritis. Rheumatology (Oxford). 2017;56(12):2190-2196.

Moreland LW, O’Dell JR, Paulus HE, et al; TEAR Investigators. A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: the Treatment of Early Aggressive Rheumatoid Arthritis trial. Arthritis Rheum. 2012;64(9):2824-2835.

O’Dell JR, Mikuls TR, Taylor TH, et al; CSP 551 RACAT Investigators. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013;369(4):307-318.

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