Background Early, remission steered treatment can prevent damage progression in patients with early rheumatoid arthritis (RA) or undifferentiated arthritis (UA).
Objectives To identify which patients during this intensive treatment strategy still develop damage progression after 2 years and which predictive factors are associated with progression in these patients.
Methods In the IMPROVED study, 610 patients with early RA (2010 criteria) or UA suspected to be early RA started treatment with methotrexate (MTX) and a tapered high dose of prednisone. If patients were in early remission after 4 months (Disease Activity Score (DAS) <1.6) prednisone was tapered to zero. After 8 months, if remission was maintained, MTX was tapered to zero. Patients not in early remission were randomized to MTX plus hydroxychloroquine, sulphasalazine and prednisone (arm 1) or to MTX plus adalimumab (arm 2). Treatment adjustments were made every four months; medication was tapered and next stopped in case of remission but increased or switched in case of no remission. Radiographs of hands and feet at baseline and at yearly intervals were scored by two independent readers, in random order and blinded for patient identity, by the Sharp/van der Heijde score (SHS). Potential predictors of radiological progression (≥0.5 SHS) were assessed using logistic regression analysis.
Results Median (IQR) SHS progression in 488 patients after 2 years was 0 (0-0) point, without difference between RA or UA patients or between treatment arms. Only 10% (50/488) of the patients had radiological progression (≥0.5 SHS): 33/50 (66%) were in the early remission group, 9 (18%) in arm 1, 5 (10%) in arm 2 and 3 (6%) were treated outside the protocol. In 8 patients (7 in the early remission group and 1 in arm 2) the progression score was ≥5 points (minimal clinically important difference) after two years. Age (OR (95% CI) 1.03 (1.00-1.06)) and the combined presence of anti-CarP (anti-carbamylated protein antibodies) and ACPA (anti-citrullinated protein antibodies) (2.54 (1.16-5.58)) were independent significant predictors for radiological progression.
Conclusions After 2 years of remission steered treatment in early arthritis patients radiological progression occurred in a small group of patients. Numerically, patients who had achieved early remission had more damage progression than other patients, maybe following treatment discontinuation. Radiological progression predictors were the combined presence of anti-CarP and ACPA and age (possibly related to osteoarthritis).
Disclosure of Interest G. Akdemir: None declared, L. Heimans: None declared, K. Wevers-de Boer: None declared, M. Verheul: None declared, A. Schouffoer: None declared, M. van Oosterhout: None declared, J. Harbers: None declared, C. Bijkerk: None declared, G. Steup-Beekman: None declared, L. Lard: None declared, T. Huizinga: None declared, L. Trouw: None declared, C. Allaart Grant/research support from: Year 1 of the IMPROVED study was sponsored by Abbott