Background Treat-to-target (T2T) is recommended and a widely accepted management strategy for rheumatoid arthritis (RA), which aims for remission or low disease activity. Disease activity is valuated by some composite measures which includes patient's and physician's global assessment, finding of joints and C reactive protein (CRP) etc. Patient's global assessment (PGA) is often the limiting factor for achieving remission. It remains unclear what is the factor contributing to elevation of PGA when finding of 28 joints and CRP implement the Boolean remission criteria.
Objectives To detect the factor contributing to elevation of PGA among Japanese RA patients whose scores on the tender joint count, swollen joint count and CRP (in mg/dl) are all 1 or less.
Methods We performed an analysis of data from 15032 RA patients registered in the large database (NinJa: National Database of Rheumatic Diseases by iR-net in Japan) of 2014 (1). Patients whose scores of the tender joint count, swollen joint count and CRP (in mg/dl) were all 1 or less were included. Patients whose PGA was 1 or less and patients whose PGA was more than 1 were compared with a probabilistic approach employing logistic regression to investigate factor contributing to elevation of PGA among Japanese RA patients whose scores on the tender joint count, swollen joint count and CRP are all 1 or less.
Results Seven thousand and two hundred and twenty-four patients were included; 5754 were women (79.7%) with a median age 65 years, a median disease duration 9 years, 826 (11.4%) had swelling or tenderness of forefoot joints which are not included in 28 joints (forefoot disease activity), 2313 (32.0%) were prescribed glucocorticoid, methotrexate 4993 (69.1%), biologic DMARDs 1986 (27.5%). In two groups; PGA ≤1 3584 (49.6%) and PGA >1 3640 (50.4%), the median modified health assessment questionnaire (mHAQ) was 0 (interquartile range: 0–0) and 0.13 (0–0.63), hospital anxiety and depression scale (HADS)-anxiety (A) was 2 (1–4) and 4 (2–7), HADS-depression (D) was 4 (2–6) and 5 (3–8), forefoot disease activity was 226 (6.3%) and 600 (16.5%), respectively. We performed the logistic regression analysis with age, Steinbrocker's stage, mHAQ, HADS-A, HADS-D and forefoot disease activity. Thereafter all variables were found factors of associating to elevation of PGA (Table).
Conclusions Forefoot disease activity, mHAQ, HADS-A and HADS-D contribute to elevation of PGA in patients who implement the Boolean remission criteria except PGA in Japanese rheumatoid arthritis patients. We should care about the foot joints in addition to functional disability and psychological distress for implementation of T2T strategy.
Matsui T, Kuga Y, Kaneko A, et al. Disease Activity Score 28 (DAS28) using C-reactive protein underestimates disease activity and overestimates EULAR response criteria compared with DAS28 using erythrocyte sedimentation rate in a large observational cohort of rheumatoid arthritis patients in Japan. Ann Rheum Dis 2007;66(9):1221–6.
Acknowledgement NinJa has been supported in part by a Health and Labor Sciences Research Grant from the Ministry of Health, Labor, and Welfare of Japan.
Disclosure of Interest K. Tokunaga Paid instructor for: AbbVie, Eisai Co. Ltd., and Mitsubishi Tanabe Pharma, A. Shiraishi: None declared, S. Takenouchi: None declared, R. Yokochi: None declared, K. Muranaka: None declared, M. Shinozaki: None declared, N. Hagino Grant/research support from: Mitsubishi Tanabe Pharma, Chugai Pharmaceutical Co. Ltd., and Bristol Meyers Squibb, Paid instructor for: Santen Pharmaceutical Co. Ltd. and Takeda Pharmaceutical Co. Ltd., J. Nishino: None declared, S. Tohma Grant/research support from: Pfizer Japan Inc., Eisai Co., Ltd and Chugai Pharmaceutical Co. Ltd.