Background Remission has become an achievable goal when treating patients with inflammatory polyarthritis (IP) and its subset rheumatoid arthritis. Previous studies suggest that early and sustained remission prevents long-term disability in patients with IP. Whether the achievement of the status of remission may also affect survival needs to be investigated.
Objectives To estimate the relationship between clinical remission and overall survival in an inception cohort of patients with IP.
Methods Consecutive patients with early IP from a primary-care based inception cohort, recruited between 1990 and 1994 (first cohort) and between 2000 and 2004 (second cohort), were eligible for this study. Patients were assessed yearly after inclusion by a research nurse and flagged with the national UK death register. Baseline assessment included a 51 tender and swollen joint count (JC), the HAQ-score; blood was collected to determine CRP, RF and ACPA. The 51- tender and swollen JC were also assessed at 1, 2 and 3 yr after registration. Remission was defined as the absence of clinically detectable joint inflammation (swollen 51-JC=0 and tender 51-JC=0). Only patients with at least 3 years of follow-up were included in the present study. Different variables for remission were evaluated: ever remission, number of assessments in remission and time of first remission within the first 3 years. All-cause death was the main outcome of this study. Censoring was set at 1st May 2011. The relationship between remission and mortality was analysed using the Cox proportional hazard regression model (start-date of survival was set at 3 yrs after inclusion). Multivariate analyses were applied to adjust for pre-specified relevant predictors, including demographics, cohort, baseline disease activity and severity, and cumulative treatment variables. Multiple imputation of predictors was used to optimize available information. The results are shown as hazard ratios (HR) and 95%CI.
Results A total of 2,769 patients were eligible for the analyses, 1,604 from the first and 1,165 from the second cohort, with a median follow-up of 105 months. 578 subjects died during the observation time. 962/2,589 (37.2%) fulfilled the predefined 51-JC remission criteria at least once within the first 3 yrs.
Having been in remission at least once within the first 3 years of follow-up was associated with a significant better survival: crude HR [95%CI] 0.81 [0.67, 0.96] and adjusted HR [95%CI] 0.80 [0.66, 0.96].
The number of times in remission was also associated with a significantly decreased risk of all-cause mortality: per each additional time spent in remission crude HR [95%CI] was 0.90 [0.82, 0.99] and adjusted HR [95%CI] was 0.90 [0.81, 0.99].
Looking at the effect of time lag until the first remission, those patients who were in remission 1 year after the first assessment had the greatest reduction in mortality risk compared to patients who never achieved remission within the first 3 years (adjusted HR 0.61 [0.43, 0.87]), while no significant association was found for patients who achieved remission at a later time point, i.e. at second (adjusted HR [95%CI] 0.80 [0.60, 1.07]) and third year (HR [95%CI] 0.97 [0.72, 1.32]).
Conclusions Early remission and sustained remission are associated with a decreased all-cause mortality in patients with IP.
Disclosure of Interest None Declared
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