Background Treating rheumatoid arthritis patients to target (T2T) with a goal of obtaining low disease activity (LDA) or no disease activity (NDA) is an attractive treatment approach and has been shown to result in better outcomes in patients with new onset or relatively recent onset rheumatoid arthritis (RA) . Implementing this strategy in a long standing rheumatology clinic is problematic with a preponderance of RA patients who have chronic diseases including deformities, severe osteoarthritis, and other comorbidities which can lead to confounding results when using traditional DAMs such as the DAS28-CRP. The ultrasound power Doppler joint count (UPDJC) and multiple biomarker disease activity (MBDA) blood test are two new options that may provide additional insights in the assessment of patients with long standing RA.
Objectives To implement a T2T strategy in a long-standing rheumatology clinic
Methods All patients with a diagnosis of rheumatoid arthritis in a long-standing rheumatology clinic underwent evaluation with DAMs including the DAS28CRP, and blood testing with a MBDA (Crescendo). Also, a method for preforming a truncated UPDJC was adopted  utilizing a subjective 0 (normal) to 3 (severe) scoring system leading to a possible score of (0-36). The LDA point for the DAS28CRP, MBDA, and UPDJC are <3.20, <30, and <6.0 respectively.
Results There were 262 patients tested with all three DAMs in the clinic.
In regards to treatment modalities used, two (<1%) patients were taking no arthritis treatments, two (<1%) patients were on only prednisone, 16 (6%) were on a biologic disease-modifying antirheumatic drug (dmard) without a non-biologic dmard, 122 (47%) were on both a non-biologic and biologic dmard, and 94 (36%) were only on a non-biologic dmard.
The average and standard deviation for the DAS28CRP, MBDA, and UPDJC were 4.27 (1.39), 42.1 (13.9), and 8.3 (4.7) respectively. These results fall in the moderate to moderate high range for disease activity for all three measures. The percentage of patients in each group that met criteria for LDA or NDA by these measures were 26%, 17%, and 28% respectively.
It is feasible to perform diverse DAMs, including non-clinically based DAMs, within the time constraints of a twenty minute office visit.
Performing these diverse DAMs facilitates decision making and the implementation of a T2T strategy in a long-standing rheumatology clinic.
These patients, though treated aggressively, demonstrate on average, moderate to high-moderate disease activity.
A more practical and obtainable T2T strategy in such a clinic would be a goal of disease activity of a mid-moderate level, such as a DAS28-CRP of 4.20.
Smolen, J. et al. Treating Rheumatoid Arthritis to Target: Recommendations of an International Task Force. Ann. Rheum. Dis 2010;69:631-637.
Shin-ya Kawashiri et. All. The power Doppler Ultrasonography Score from 24 Synovial Sites or 6 Synovial Sites, including the MCP joints, reflects the Clinical Disease Activity and Level of Serum Biomarkers in Patients with RA. Rheumatology (2011) 50 (5): 962-965.
Disclosure of Interest None declared