Optimization of Treatment With Adalimumab (Humira)

The purpose of this trial is to assess the effect of two Intensive Outpatient Management Strategies (IOMS) versus Routine Care (RC) on the outcomes of patients with Rheumatoid Arthritis (RA) that are treated with adalimumab.

This is a multi-center, randomized, controlled, parallel group, single (patient) blind trial. A total of 300 patients (100 per group) with RA will be recruited from approximately 40 sites across Canada.

Background:

Rheumatoid arthritis (RA) is chronic systemic inflammatory disease often leading to damage and disability (Lee DM, et al.). RA is associated with a shorter life expectancy (Pincus T, et al.) and, if untreated, can lead to significantly lower quality of life and functional impairment (Bradley EM, et al.).

The concept of tight control, involving the treatment of patients to specified targets with close monitoring and treatment adjustment when necessary, has been trialed in early RA. Many targeted studies have demonstrated improved outcomes or faster target achievement in early RA.

The TICORA trial, which studied a group of patients who had active disease but who had not progressed to multiple DMARDs or biologic therapy, demonstrated that the usage of an intensive outpatient management strategy (IOMS) of RA improved clinical outcomes measures (Grigor C, et al.). Indeed, the results from this clinical trial have shown that strict control and intense follow up, which are based on titration of treatment in accordance to a standardized protocol, improved disease activity, physical function and quality of life of patients without additional cost.

The proposed study will evaluate the application of two types of IOMS. The first IOMS will consist of titration of treatments based on the attainment of a DAS28 score under 2.4 (DAS28-IOMS). The second IOMS will consist of titration of treatment based on the attainment of zero swollen joints (0SJ-IOMS) (28 joints evaluated). Investigators should aim at achieving those targets within a reasonable period of time, i.e. during the first six months of treatment with adalimumab. In addition, investigators should aim at attaining these targets within reasonable limits for each individual patient. The clinical impact of these two IOMS will be compared to that of routine care (RC).

The results of this study will have significant implications not only for the individual subjects but also from the societal perspective since it may enhance the overall real-life effectiveness of the treatments and will identify the best approach to maximize on the benefits of treatment with HUMIRA®.

Primary Objective:

In patients with RA that are initiated on treatment with adalimumab:

* The primary aim of the current study will be to assess the effect of two IOMS versus RC on the outcomes of patients with RA that are treated with adalimumab. The secondary aim will be to assess the differential effect of a DAS28-IOMS and a 0SJ-IOMS in this patient population.

Secondary Objectives:

In patients with RA that are initiated on treatment with adalimumab:

* To compare the therapeutic effectiveness of DAS28-IOMS, 0SJ-IOMS and RC as measured by the proportion of subjects achieving target scores of the DAS28.
* To compare the impact of DAS28-IOMS, 0SJ-IOMS and RC on patient subjective assessment of functional status as measured by the Health Assessment Questionnaire (HAQ).
* To compare the impact of DAS28-IOMS, 0SJ-IOMS and RC on patients' perception of their disease as evaluated by the Work Limitation Questionnaire (WLQ).
* To compare the impact of DAS28-IOMS, 0SJ-IOMS and RC on patients' satisfaction with care as evaluated by the change of patients' satisfaction measured on a Likert scale.
* To compare the therapeutic effectiveness of DAS28-IOMS, 0SJ-IOMS and RC as measured by the proportion of subjects achieving good or moderate European League against Rheumatism (EULAR) responses.
* To compare the impact of DAS28-IOMS, 0SJ-IOMS and RC on the frequency of serious adverse events or protocol-specified adverse events.

Tertiary Study Objectives:

In patients with RA that are initiated on treatment with adalimumab:

* To compare the therapeutic effectiveness of DAS28-IOMS, 0SJ-IOMS and RC as measured by the proportion of subjects achieving target scores of the CDAI and the SDAI.
* To describe the impact of individual components of the DAS28 on clinical decisions regarding patient management.
* To describe the impact of the CDAI on clinical decisions regarding patient management.
* To describe the impact of the SDAI on clinical decisions regarding patient management.
* To describe the impact of the HAQ on clinical decisions regarding patient management.
* To describe and compare the impact of a DAS28-IOMS, 0SJ-IOMS and RC on patients' compliance to treatment.
* To describe and compare the impact of a DAS28-IOMS, 0SJ-IOMS and RC on changes in concomitant anti-rheumatic medication use.

Eligibility Criteria:
Inclusion Criteria:

* Patient has a diagnosis of rheumatoid arthritis
* Patient is \> 18 years of age
* Patient is naïve to HUMIRA® (adalimumab) therapy.
* Patient has access to reimbursement for their standard of care.
* If female, patient is either: 1) not of childbearing potential, defined as postmenopausal for at least 1 year or surgically sterile (bilateral tubal ligation, bilateral oophorectomy or hysterectomy), or 2) of childbearing potential and practicing one of the following methods of birth control:

  * condoms, sponge, foams, jellies, diaphragm or intrauterine device (IUD)
  * contraceptives (oral or parenteral) for three months prior to enrollment in the study
  * a vasectomized partner
  * total abstinence from sexual intercourse
* If female and of childbearing potential, patient must have a negative serum pregnancy test performed at Screening.
* Patient is able to give written informed consent and to complete the survey requirements.

Exclusion Criteria:

* Patients had a history of cancer within the past 5 years other than a successfully treated basal cell carcinoma and/or localized carcinoma in situ of the cervix
* Patients with a history either of lymphoma or leukemia.
* Patients with a history of untreated active tuberculosis, or listeriosis, or other currently active infections suggestive of significant or profound immunosuppression, such as Pneumocystis carinii, aspergillosis or other systemic protozoal or fungal infections.
* Patients with a known positive HIV test.
* Patients with a known positive HepBsAg test.
* Patients with a persistent or severe infection(s) requiring hospitalization or treatment with iv antibiotics within 30 days, or oral antibiotics within 14 days, prior to enrollment.
* Female patients who are breast-feeding.
* Patients with clinically significant concurrent illness that in the investigator's judgment may influence the study outcomes (such as MS, moderate to severe CHF, etc,).
* Patients with any condition that would prevent participation or completion in this study including language limitation or possibility that the patient will not be available for the complete study period (18 months).