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Women with rheumatoid arthritis who were taking oral contraceptives or hormone replacement therapy had a greater chance of achieving remission, according to a new study that has been welcomed by the Australian Rheumatology Association.
New Australian research has found that women with rheumatoid arthritis who were taking oral contraceptives or hormone replacement therapy had a greater chance of achieving remission than women who were not taking sex hormones.
Researchers at the University of South Australia made the link between remission, reproductive status, and sex hormone use, by analysing published data on 4474 female rheumatoid arthritis patients who had participated in clinical trials where they were treated with the anti-inflammatory medication tocilizumab and other immuno-suppressive medications.
The research, published in Rheumatology, found that perimenopausal women were 22% less likely to achieve remission than premenopausal women.
It also found that women with rheumatoid arthritis using hormone replacement therapy or oral contraceptives in combination with the medications prescribed for rheumatoid arthritis had a remission rate that was 20% higher than women who were not taking sex hormones.
The study did not find a statistically significant difference in remission in post-menopausal women compared with pre-menopausal women.
“Too early” for treatment regimen changes
Lead researcher Associate Professor Michael Wiese, from the University of South Australia, told InSight+ that it is too early to say if hormone replacement therapy has a protective effect against rheumatoid arthritis.
“Our findings hopefully provide some information to patients and clinicians as to the disease prognosis,” Associate Professor Wiese said.
“A question that may be asked as a result of this data is if women with rheumatoid arthritis should take hormone replacement therapy or hormonal contraception.
“Unfortunately, this wasn’t a trial where women were randomised to oral contraceptives or hormone replacement therapy.
“Rather we observed what occurred in women who were taking these medicines by choice, so it really is too early to say that our analysis should provoke changes to current rheumatoid arthritis management or treatment guidelines.”
Associate Professor Wiese said he and his team were keen to explore whether a woman’s overall exposure to sex hormones may be associated with treatment outcomes.
“When we decided to ask this question, we always suspected that we would find something interesting, but at the same time there are always some surprises when you see the final analysis,” he said.
Associate Professor Wiese said the data used for the study were obtained from five pharmaceutical company-sponsored trials that made their data available for secondary analysis.
“This is a relatively new initiative aimed to promote transparency of this clinical trial data, to allow independent researchers to ask (and answer) novel research questions and to get the most insight out of these particularly large datasets,” he said.
“Participants from these trials were recruited from all over the world.”
New research “interesting”
Commenting on the research for InSight+, Australian Rheumatology Association Vice President, Dr Samuel Whittle, said it was too soon to adjust existing treatment regimens.
“This piece of research is an interesting addition to the body of research that has attempted to understand the complex interplay between sex hormones, particularly oestrogens, and the development and disease course of many autoimmune diseases, including rheumatoid arthritis,” Dr Whittle said.
“As is often the case with interesting and novel research, it probably raises more questions than it answers.
“It is certainly too soon to know whether exogenous hormones might ever form part of the treatment algorithm for women with rheumatoid arthritis.
“Evidence from randomised controlled trials of hormonal interventions would be required to determine whether this truly offers an incremental benefit over current disease-modifying antirheumatic drugs (DMARD) regimens, and whether any potential incremental benefit of adding hormone therapy to current DMARD regimens would be of sufficient magnitude to outweigh the potential risks.”
Shortage of rheumatologists
Dr Whittle, a senior consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide, said despite a shortage of rheumatologists, they prioritised referrals where a patient showed early symptoms of rheumatoid arthritis.
“We are always keen to see patients who present with inflammatory forms of arthritis as soon as possible after the onset of their symptoms, since we know that the response to DMARD treatment is often much better when it is instituted very early in the disease course,” he said.
“A major focus of the Australian Rheumatology Association at present is to try to expand the rheumatology workforce, as we know that there is a relative shortage of rheumatologists throughout Australia, particularly outside of the major metropolitan areas.
“This has led to increasingly long waiting times to see rheumatologists in both the public and private sectors; however, all rheumatologists are very keen to help to expedite specialist review of people with suspected inflammatory arthritis.”
There is currently no cure for rheumatoid arthritis, but Dr Whittle said modern treatment regimens are highly effective at treating the symptoms and signs of the disease.
“There are a number of medications, described as DMARDs, which are used either alone or in combination by rheumatologists to treat rheumatoid arthritis.
“In recent years, highly specific immunomodulatory treatments (biological and targeted synthetic DMARDs) have proven to be very effective treatments for most patients.
“In addition, increasing recognition over the last couple of decades that early institution of DMARD therapy and escalation of therapy to achieve remission of the disease (known as the ‘treat-to-target’ approach) has further improved outcomes for people with rheumatoid arthritis.”
Further advice
As treatment regimens have become increasingly complex, so has the task of the rheumatologist to help patients to design a treatment plan that is based on the best evidence and is tailored to the individual patient, Dr Whittle said.
The Australia and New Zealand Musculoskeletal Clinical Trials Network has developed an Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis, which aims to produce living recommendations based on a synthesis of the latest evidence. The guideline is freely available and is designed to be used by clinicians and patients at the point of care.
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I find this study particularly intriguing and potentially promising. The idea that oral contraceptives or hormone replacement therapy could increase the likelihood of achieving remission is quite encouraging. It’s reassuring to see research in this area being welcomed by organizations like the Australian Rheumatology Association. I’ll definitely be discussing these findings with my healthcare provider to see if they might be relevant to my treatment plan. Thank you for sharing this valuable information.