Background Joint damage in rheumatoid arthritis (RA) is thought to be irreparable. We hypothesized that in patients where inflammation is well suppressed for a long time, repair may be possible.
Objectives To investigate whether reversal of erosions and joint space narrowing (JSN) in RA occurs and whether clinical variables predict repair.
Methods In the BeSt study, patients with active early RA (ACR 1987 criteria, arthritis symptoms <2 years) were randomized to 4 treatment strategies, each with the aim to ensure and maintain suppression of disease activity by adjusting medication based on three-monthly calculations of the 44-joint Disease Activity Score (DAS), target ≤2.4. Radiographic joint damage was assessed yearly, using the Sharp/van der Heijde score (SHS). In this analysis, 8-years data of the study were used. Repair of erosions or JSN was defined at the individual joint level as a reduction of ≥1 SHS point compared to the previous available X-ray, present in ≥2 consecutive visits and with ≥3 out of 4 independent scorers agreeing. Radiographs were scored in random order per patient, blind for patient identity and treatment arm. Multiple logistic regressions were applied at the patient level for associations between achieving repair and maximum duration of previous remission, mean DAS until repair, previous prednisone use, previous infliximab use, anti-citrullinated protein antibody (ACPA), gender, age and randomization arm. All models were adjusted for mean joint damage over time in the group with repair. In the group without repair, the models were corrected for mean damage over time until mean time point of repair in the group with repair.
Results Seven out of 508 patients did not have any X-ray images taken in the study. Of the remaining 501 patients, 320 had damage in at least 1 joint and thus could potentially show repair. In total, 2395 X-rays were available, on average 7.5 per patient (range 2–9). Median SHS after 8 years in these patients was 10 (IQR 4–21, range 0–234), and mean (SD) DAS from month 3 was 2.00 (0.67). Repair was seen in 17 patients, 3.3%; 10 had reduction of JSN, 6 of erosions, 1 had repair of both JSN and erosions. In 14 patients repair was seen in 1 joint, in 3 patients repair was seen in 2 joints (same time point). Mean (SD) time to repair was 44.1 (20.1) months. Ten of 17 patients (59%) had previously achieved DAS-remission, compared to 100% of the patients who at a matching time point showed no repair. Adjusted for mean SHS until repair, we found no associations with repair for duration of remission, mean DAS until repair, gender, age, presence of ACPA, or previous exposure to prednisone or infliximab (table 1). Apart from a trend towards fewer patients with repair in the initial infliximab study arm, there were no differences in any of the groups in any of the regression analyses.
Conclusions In this early RA cohort, during 8 years treated to target DAS ≤2.4, repair of JSN and erosions was seen in 17 patients (3.3%), which supports that repair occurs in early RA. However, repair is a rare phenomenon, and does not seem to relate to previous inflammation or other predictors in this cohort.
Disclosure of Interest J. van der Pol: None declared, G. Akdemir: None declared, M. van den Broek: None declared, L. Dirven: None declared, P. Kerstens: None declared, W. Lems Speakers bureau: Speakersfee/advosory boards Pfizer, MSD, Eli Lilly, Abbvie, I. Markusse: None declared, T. Huizinga: None declared, C. Allaart Grant/research support from: The BeSt study was supported by a government grant from the Dutch Insurance Companies, with additional funding from Schering-Plough B.V. and Janssen B.V.