Background Flares, potentially disabling and disease worsening even when a patient is in low disease activity, are common features in patients with rheumatoid arthritis (RA) that may escape the routine clinical control. Consequently the current treat-to-target goal to achieve remission or low disease activity fails to take into account the potential of flares to represent the persistence of disease activity. It remains unknown whether patient reported flares can worsen radiographic joint damage.
Objectives To investigate whether patient reported flares increase the risk for radiographic progression.
Methods From 287 patients included in the AMBRA trial (1), 268 RA patients with low disease activity (DAS28-CRP <3.2, and no swollen joints at baseline) with radiographs available at baseline and 2 year of follow-up and data about flares, were included in the analyses. At an annual clinical evaluation the patients were asked to recall the occurrence of flares during the past year, according to: No flares, transient flares or persistent joint complaints with tender and swollen joints. X-rays of hands and feet were scored according to the Sharp/van der Heijde method. The change in Total Sharp Score (TSS) and its components (Joint Space Narrowing (JSN) and Erosions (E)) were calculated. The proportion of patients who progressed (ΔTSS/ ΔJSN/ ΔE >0 units) across the three groups were compared and the association between flare phenotype and radiographic progression was analyzed by logistic regression.
Results 70% of patients were women, median age [IQR] was 63 years [55;70], 73% were rheumatoid factor positive, 71% anti-CCP positive and all had established RA (median [IQR] 7 years [4;13]). Radiographic progression depicted by ΔTSS, ΔJSN, and ΔE, respectively, was seen in 35%, 8%, and 30% of no-flares group (n=77); 37%, 18%, and 32% of patients with transient flares (n=141) and in 46%, 24%, and 34% of patients with persistent joint complaints (n=50). Only differences in worsening of JSN were statistically significant (P=0.038).The flare phenotype was significantly related to worsening in JSN (Figure 1); OR was 2.55 (95%CI, p) (1-6.52, p=0.051) for the transient flares group and 2.12 (1.15-3.91, p=0.016) for the group with persistent joint complaints compared to patients without flares. Defining clinically relevant progression as ≥ smallest detectable change (SDC) of 4.4 TSS units, 14 (10%) patients in the flares group and 7 (14%) patients with persistent joint complaints progressed, compared to none in the no-flares group.
Conclusions RA patients with established low active disease, who report transient flares and persistent joint complaints with tender and swollen joints, have more radiographic damage on JSN compared to no-flares patients.
Primdahl J, et al.: Ann Rheum Dis 2014; 73: 357-364
Disclosure of Interest None declared