Background The 2010 treatment to target guidelines recommend frequent assessment to achieve a pre-defined target (ideally remission) in early rheumatoid arthritis (RA) . Power Doppler (PD) ultrasound has the ability to identify sub-clinical activity .
Objectives To evaluate change in clinical outcome with implementation of Treat to Target guidelines, and impact on achievement of ultrasound remission (absence of PD).
Methods A prospective clinical audit of patients with early RA (time since diagnosis ≤12 months) commencing initial DMARD therapy after implementation of Treat to Target guidelines (“T2T Group”) at Chapel Allerton Hospital (Leeds, UK), between April 2010 and June 2011 was conducted. The target for treatment was set at baseline as DAS28 remission (DAS28-CRP<2.6). Clinical outcomes were compared to data obtained from YEAR (the Yorkshire Early Arthritis Register), a prior observational registry of early RA managed according to a pre-defined treatment protocol.
Results Of 104 T2T patients, 5 were excluded from the analysis (2 lost to follow-up, 3 enrolled in clinical trials within the 6-month follow-up period). Of the 99 patients, 69 (70%) were female, 75 (76%) were rheumatoid factor positive and 23 (23%) had radiographic erosions. Baseline mean (SEM) characteristics included: age 56 (1.4) years, symptom duration 11 (1.1) months and DAS28 4.8 (0.1). The shared epitope was present in 26 out of 29 patients tested. Baseline characteristics in YEAR (n=1581) were similar (66% female, 67% rheumatoid factor positive, 25% radiographic erosions, mean age 58) with the exception of positivity for shared epitope (positive in 612 of 913 tested) and DAS28 (mean 5.4; SEM 0.4). Disease activity outcomes are summarised in table 1. In the T2T group, of patients achieving the clinical target at any time point over the 6 months follow-up (n=43), ultrasound was available in 21; any PD signal was present in approximately half of these patients (12/21), and PD grade ≥2 in at least one joint was present in 8/21.
Conclusions Despite implementation of Treat to Target approach, an obvious improvement in remission rates by 6 months was not observed. The basis for this is being evaluated. However, PD US suggests achievement of the clinical target is associated with continued PD presence suggesting residual inflammatory activity.
Smolen JS, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69(4):631-7.
Brown AK, et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum 2008;58(10):2958–67.
Disclosure of Interest S. Horton: None Declared, S. Twigg: None Declared, D. Pickles: None Declared, E. Hensor: None Declared, J. Freeston: None Declared, A. Tan: None Declared, R. Wakefield: None Declared, P. Emery Grant/Research support from: Bristol-Myers Squibb, Pfizer, Consultant for: Abbott, Roche, Bristol-Myers Squibb, Pfizer, M. Buch Grant/Research support from: Bristol-Myers Squibb, Pfizer, Consultant for: Abbott, Roche, Bristol-Myers Squibb