LAUSR

Over the past few decades, several recommendations have been published to guide the management of rheumatoid arthritis (RA). 2 However, successful implementation of these guidelines in clinical practice has lagged behind. In 2019, the European Alliance of Associations for Rheumatology (EULAR) published updated recommendations for the management of RA with conventional synthetic diseasemodifying antirheumatic drugs (csDMARDs) and biological diseasemodifying antirheumatic drugs (bDMARDs). Few studies have characterised realworld challenges to effective implementation of RA management algorithms in Asian countries. Leveraging data collected from the Chinese Registry of Rheumatoid Arthritis (CREDIT; see online supplemental materials), we sought to examine the degree of concordance between RA management in China and the 2019 EULAR recommendations. Patients from CREDIT were eligible for inclusion in the present study if they had newly diagnosed RA based on the 2010 American College of Rheumatology (ACR)/EULAR RA classification criteria, moderate to high disease activity (clinical disease activity index (CDAI) >10) at baseline, without severe extraarticular involvement that may affect treatment strategies. The initial treatment for a given patient was considered consistent with the EULAR recommendations if the patient initiated csDMARD monotherapy. Patients were then followed longitudinally to evaluate whether timely treatment escalation at 3 and 6 months occurred if treatment targets of remission or low disease activity were not achieved. Associations of these outcomes with patient, provider and healthcare settingrelated factors were identified via multivariable logistic regression analyses. All data analysed in the present study were part of patients’ ‘core data’, which were required to be fully completed for all patients on entry into the CREDIT registry. Therefore, missing data were not a problem in our analyses. A total of 12 030 patients (76.4% women, aged 50.2±14.6 years) were included (see flowchart shown in online supplemental figure 1), of whom 2669 (22.2%) underwent csDMARD monotherapy. The numbers of methotrexate, leflunomide and sulfasalazine monotherapy users were 1646, 994 and 29, respectively. The average dose of methotrexate was 12.5 mg. Combination csDMARDs were initiated in 6111 patients (50.8%), and 1504 (12.5%) initiated biologics or JAK inhibitors. Combination glucocorticoid therapy was used in 28.7% of patients on csDMARD monotherapy, in 38.8% of patients on combination csDMARDs and in 19.1% of biologics users. Concordance of initial treatment with 2019 EULAR recommendations was associated with younger age, shorter disease duration, lower disease activity and having a more senior provider (table 1). Longitudinal followup of patients undergoing csDMARD monotherapy demonstrated 193/351 patients (55%) had insufficient improvement (50% decline in CDAI) within 3 months, of whom 31% had treatment escalation. At 6 months, 113/189 (60.0%) patients failed to reach remission or low disease activity, 47.8% of whom had their treatment escalated. More experienced rheumatologists were more likely to escalate therapy within the recommended time frame. A wide gap between recommended care for RA and clinical practice has been shown in Western countries. A cohort study in the USA showed that less than half of patients had timely treatment escalation, concordant with ACR recommendations. In our study, management of RA also demonstrated poor concordance with the 2019 EULAR recommendations. At baseline, csDMARD monotherapy was given to only onefifth of our patients, although it is the preferred treatment approach for newly diagnosed patients. Methotrexate was given to 77% of combination therapy users. Although it was consistent with the recommendation of including methotrexate in initial treatment, combination therapy was not preferred for efficacy and safety reasons. In line with treattotarget (T2T) strategies, therapy should be escalated if there is no improvement by 3 months, or if the target has not been achieved by 6 months. In this study, less than half of the patients had timely adjustment after failure of the first strategy, suggesting a lack of adherence to the T2T approach in China. There are numerous barriers to the implementation of clinical recommendations. Incomplete understanding of the recommendations, concerns about drug safety, costs and patient compliance have all been reported to impact provider decisions. Challenges in China also include workforce shortages, limited access to information in lowincome areas, lack of patient education and deficiencies in the health insurance system. Increasing efforts have been made to overcome these barriers. In 2018, the Chinese guideline for management of RA was published, and more medications have been added Letter