Background With implementation of tight control strategies and defined treatment targets in rheumatoid arthritis (RA) care, a majority of early RA patients may reach remission and traditional predictors of joint damage might no longer be present.
Objectives To identify baseline parameters predictive of 2-year radiographic progression in an early RA population treated by a semi-personalized treat-to-target strategy.
Methods DMARD naïve RA patients with <2 years from first swollen joint were included in the ARCTIC study. Patients were followed for 24 months with DAS, radiographs and ultrasound (32 joints, each scored 0–3 for gray-scale (GS) and power-Doppler (PD)). Patients were treated according to an aggressive algorithm with treatment target of DAS <1.6 and SJC44=0, and in half the patients, absence of ultrasound PD signal. Patients with risk factors for progressive joint destruction (ACPA or RF positive with baseline erosions, or MRI bone marrow edema) could be escalated more aggressively to biologics. Radiographs were scored by two readers using the van der Heijde-Sharp method, with cut-off ≥1 unit change/year to be classified as progression. The SDC was 1.94 units. Potential baseline predictors were analyzed for collinearity, and remaining variables (gender, age, smoking, BMI, disease duration <3 months, ACPA, RF, tender joints, 44 SJC, ESR, total GS-score, total PD-score, patient global and radiographic joint damage) assessed by univariate logistic regression. Variables with p<0.25 from the univariate analysis were included in the multivariate model building, and a p-value of <0.05 was required to remain in the model.
Results Mean [SD] age of the 222 patients was 51.1 [13.7] years, disease duration 7.2 [5.4] months, and mean DAS 3.5 [1.2]. 63% were female, 72% RF and 82% ACPA positive. 92 (41%) had radiographic progression at 24 months, and 68% were in DAS remission at 24 months. In 16% of patients treatment was escalated more rapidly from MTX monotherapy to biologics due to baseline risk factors. Smoking, tender joints, 44 SJC, ESR, PD-score, age and gender had a univariate p-value<0.25 but did not remain in the final model. In the multivariate model, RF positivity (OR 2.27, p-value 0.022), total van der Heijde Sharp score (OR 1.08, p-value 0.017) and ultrasound GS score (OR 1.03 per unit, p-value 0.019) were independent baseline predictors for radiographic progression at 24 months (table).
Conclusions RF positivity, radiographic joint damage and ultrasound gray-scale score were independent baseline predictors of joint damage in early RA patients treated according to an aggressive regimen aiming for remission. This indicates that extensive individualization of treatment based on risk factors might be needed to optimize disease outcomes, also in treat-to-target strategies.
Disclosure of Interest None declared