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THU0248 Three-Year Sustained Remission in Early RA: Predictors and Structural Outcomes. Analysis of Longitudinal Observational Data in Two Multicentre UK Inception Cohorts over 25 Years
  1. E. Nikiphorou1,
  2. S. Norton3,
  3. L. Carpenter2,
  4. J. Dixey4,
  5. P. Kiely5,
  6. D. Walsh6,
  7. A. Young7
  8. on behalf of ERAS & ERAN
  1. 1School of Life & Medical Sciences
  2. 2Centre for Lifespan & Chronic Illness Research, University of Hertfordshire, Hatfield
  3. 3Psychology Department, Institute of Psychiatry, King's College London, London
  4. 4Department of Rheumatology, New Cross Hospital, Wolverhampton
  5. 5Department of Rheumatology, St Georges Healthcare Trust, London
  6. 6Arthritis UK Pain Centre, University of Nottingham, Nottingham
  7. 7ERAS, Rheumatology Department, St Albans City Hospital, St Albans, United Kingdom

Abstract

Background Achieving sustained remission in Rheumatoid Arthritis (RA) is more important than achieving point remission, albeit more challenging, and likely to have greater impact on long-term outcomes of disease such as orthopaedic surgery (OS).

Objectives To examine baseline predictors and OS, a surrogate marker of joint destruction, in RA patients with sustained disease activity score (DAS) remission over the first 3 years (3yrRem).

Methods Using a single mode of data collection, 1465 DMARD naïve patients were recruited into the Early RA Study (ERAS, 9 centres, 1986-1998) & 1236 patients into the Early RA Network (ERAN, 23 centres, 2002-2012). Standard clinical, radiological & laboratory measures were performed yearly for a maximum 25 & 10yrs (median 10 & 3yrs respectively). 3yrRem was defined as persisting DAS of ≤3.2 at 6 months (following treatment-onset), 1, 2 & 3 yrs. In-patient hospital episodes were recorded yearly, including OS. Major OS (M-OS) included large total joint replacements (mainly hips/knees) & intermediate OS (I-OS) included hand/foot surgery. Source data of all OS included clinical datasets (patient reports & medical records from 1986) & national data from Hospital Episode Statistics & the National Joint Registry. Length of follow up was based on the National Death Registry. Treatment regimens followed guidelines of the era, mainly conventional DMARDs, +/− steroids & latterly biologics.

Results Out of 2701 patients, 154 (5.7%) were in 3yrRem following onset of treatment. In Logistic regression analysis, baseline DAS was the single clinical/laboratory predictor (OR 0.60, p<0.001) for achieving 3yrRem, along with male gender (OR 2.57, p<0.001). In Cox regression models controlling for age at disease-onset, gender as well as baseline clinical/laboratory variables, the likelihood of having M-OS was more than halved if in the 3yrRem group (HR 0.43, p<0.05). There was a similar trend for I-OS, although non-significant (p=0.07), suggesting that those in sustained remission also had a lower risk of this surgery. Fig1 shows the cumulative hazard for M-OS & I-OS in those with 3yrRem versus those with active disease. Male gender, body mass index (BMI), erythrocyte sedimentation rate (ESR), erosions & haemoglobin (HB) at baseline were all significant predictors of I-OS, while age at disease-onset, BMI, erosions & HB were all significant predictors of M-OS (p<0.05).

Figure 1.

Cumulative hazard plots of intermediate (a) and major (b) surgery by DAS category.

Conclusions Baseline DAS was the single predictive clinical/laboratory variable for achieving 3yrRem, along with male gender. The results highlight the importance of early DAS remission with early & intensive medical intervention to increase the likelihood of sustained remission in later years. Patients achieving 3yrRem had significantly lower incidence of M-OS compared to those with active disease. Possible explanations for differences seen between M-OS and I-OS include the effect of secondary degenerative joint pathology with older age; ongoing subclinical joint inflammation; joint destruction despite apparent remission. The findings have several implications including the most appropriate timing for treatment withdrawal for those in remission.

Disclosure of Interest : None declared

DOI 10.1136/annrheumdis-2014-eular.4414

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