The STRATEGE studies reveal dramatic shifts in RA patient profiles and treatment approaches between 2014 and 2020
For decades, rheumatoid arthritis (RA) meant inevitable joint damage, chronic pain, and progressive disability. But the landscape of RA treatment has undergone a remarkable transformation in recent years. The STRATEGE studies provide compelling evidence of how rheumatologists' approaches to managing this complex autoimmune condition have evolved dramatically between 2014 and 2020, reflecting broader shifts in treatment philosophy and medication availability.
This revolution isn't just about new drugs—it's about smarter treatment strategies, changing patient profiles, and a fundamental rethinking of what's possible for people living with RA.
Let's explore what these changes mean for patients and the future of arthritis care.
Rheumatoid arthritis has traditionally been considered a disease primarily affecting women in their 30s to 50s. However, societal aging, decreased mortality, and rising age of RA onset have significantly shifted this demographic picture 2 . The elderly now constitute the majority of patients with RA, presenting new challenges in management as many have greater risk of comorbidities such as malignancy, infection, osteoporosis, chronic kidney disease, and lung disease 2 .
This demographic shift has compelled rheumatologists to adapt their treatment strategies, particularly when initiating advanced therapies.
Understanding these demographic shifts helps explain why treatment approaches needed to evolve so rapidly within the short five-year timeframe.
The STRATEGE studies captured a crucial transition period in rheumatoid arthritis management. STRATEGE1 was conducted in 2014-2015, while STRATEGE2 followed in 2019-2020 1 .
STRATEGE1 included 117 patients initiating b/tsDMARD therapy out of 854 total patients, while STRATEGE2 expanded to 230 patients, with 180 in the final analysis population 1 .
Baseline assessment of patient characteristics and treatment approaches at the initiation of first targeted therapy.
Significant changes in clinical practice, medication availability, and treatment philosophy.
Follow-up study revealing how patient profiles and treatment strategies had transformed.
The comparison between STRATEGE1 and STRATEGE2 revealed several noteworthy changes in the typical patient starting targeted therapy:
| Characteristic at Baseline | STRATEGE1 (2014-2015) | STRATEGE2 (2019-2020) | Significance |
|---|---|---|---|
| Mean age (years) | 52.6 ± 12.5 | 56.4 ± 13.6 | Significant increase (p=0.0158) |
| Mean Disease Activity (DAS28) | 4.6 ± 1.1 | 4.3 ± 1.2 | Significant decrease (p=0.0074) |
| Mean Disability (HAQ) | 1.4 ± 0.9 | 1.0 ± 0.7 | Significant improvement (p<0.0001) |
| Oral MTX use | 44.0% | 28.9% | Significant decrease (p=0.0088) |
| Subcutaneous MTX use | 52.6% | 70.6% | Significant increase (p=0.003) |
| Corticosteroid therapy | 53% | 50.6% | Not significant |
Patients in STRATEGE2 were significantly older when starting their first targeted therapy 1 . This reflects growing confidence in using these medications in older patients with potentially more comorbidities.
Patients in the later study had lower disease activity and less functional disability at treatment initiation 1 . This suggests more proactive use of advanced therapies.
The STRATEGE studies also revealed dramatic changes in treatment approaches and medication choices:
| Treatment Aspect | STRATEGE1 (2014-2015) | STRATEGE2 (2019-2020) | Key Shift |
|---|---|---|---|
| bDMARD initiation | 100% | 88.9% | Introduction of tsDMARDs |
| tsDMARD initiation | 0% | 11.1% | New drug class availability |
| Anti-TNF therapies | 78.8% | 58.3% | Broader drug class diversification |
| IL-6 inhibitors | 6.7% | 12.8% | Increased usage |
| CTLA4-Ig (abatacept) | 11.5% | 16.7% | Increased usage |
| MTX regimen maintained | 69.2% | 76.1% | More stable concomitant therapy |
| Primary reason for adjustment: Active RA | 86.1% | 77.8% | Evolving adjustment criteria |
Notable diversification in treatment options beyond traditional anti-TNF drugs 1 .
Marked shift from oral to subcutaneous MTX administration, with self-administration jumping from 53.8% to 75.8% 1 .
The expanded toolkit allows for more personalized treatment approaches based on individual patient characteristics.
The broader therapeutic arsenal allows for more personalized approaches.
Trend toward initiating targeted therapies earlier may help prevent irreversible joint damage.
Diversification away from heavy reliance on anti-TNF drugs is particularly significant.
Research shows different drug classes have varying strengths—TNF inhibitors tend to show higher remission rates but lower retention rates, while IL-6 receptor inhibitors and CTLA4-Ig often show the opposite pattern, suggesting they may be particularly valuable for difficult-to-treat patients 2 .
The STRATEGE studies reflect an expanded toolkit for rheumatologists managing rheumatoid arthritis:
| Therapy Category | Key Examples | Mechanism of Action | Clinical Considerations |
|---|---|---|---|
| TNF Inhibitors | Infliximab, adalimumab, etanercept | Block tumor necrosis factor, a key inflammatory cytokine | Often first-line biologics; high remission rates but lower retention |
| IL-6 Receptor Inhibitors | Tocilizumab, sarilumab | Block interleukin-6 signaling | Particularly beneficial for patients with history of malignancy 2 |
| CTLA4-Ig | Abatacept | Modulates T-cell activation | Recommended for patients at high infection risk 2 |
| JAK Inhibitors | Tofacitinib, baricitinib | Block intracellular signaling pathways | Oral administration; requires careful cardiovascular risk assessment 9 |
| Biosimilars | Multiple options | Similar to reference biologics | Increase access through cost savings 8 |
This expanded arsenal allows for truly personalized treatment approaches based on individual patient characteristics, comorbidities, and preferences.
Different drug classes offer varying risk-benefit profiles, allowing clinicians to match treatments to specific patient needs and risk factors.
Despite these advances, significant challenges remain in RA management. Difficult-to-treat RA (D2T RA) persists in approximately 5.9-23.8% of patients 5 . Recent research shows that about 45% of D2T RA cases can resolve over five years with further treatment modifications, particularly through interleukin-6 receptor inhibitors use and additional treatment changes 5 .
The STRATEGE studies capture a healthcare system in transition—a quiet revolution in how we approach rheumatoid arthritis. In just five years, we've seen significant shifts in when we start advanced therapies, which patients receive them, and which medications we choose first.
These changes reflect both increasing clinical confidence with targeted therapies and a growing recognition that earlier, more personalized intervention can dramatically alter the disease trajectory for millions living with rheumatoid arthritis.
While challenges remain, the evolution in RA management offers hope for continued improvements in quality of life for patients facing this chronic condition.
The story of RA treatment transformation reminds us that medical progress isn't always about dramatic breakthroughs—sometimes it's about steady, incremental refinements in who we treat, when we treat, and how we think about complex chronic diseases.