Session Title: Plenary Session II: Discovery 2012
Session Type: Plenary Sessions
To evaluate the 1 year clinical and radiological outcomes of remission steered therapy in early arthritis patients treated aiming at remission (DAS<1.6).
In the IMPROVED study 610 patients were included with early rheumatoid or undifferentiated arthritis (RA or UA). All patients started with methotrexate (MTX) 25mg/wk and prednisone 60mg/day tapered to 7.5mg/day in 7 weeks. Patients in remission (DAS<1.6) after 4 months (early remission) tapered prednisone to zero and, when in remission at 8 months, tapered MTX. Patients not in early remission were randomized either to a combination of MTX 25mg/wk, hydroxychloroquine 400mg/day, sulphasalazine 2000mg/day and prednisone 7.5mg/day (arm 1) or to adalimumab (ADA) 40mg/2weeks with MTX 25mg/wk (arm 2). If not in remission after 8 months, patients in arm 1 switched to ADA+MTX and patients in arm 2 increased ADA to 40mg/week. Proportions of remission and radiological progression measured by Sharp-van der Heijde scoring method after one year follow up were compared between the different treatment strategies.
After 4 months 375 patients (61%) achieved early remission and 221 (36%) did not, of which 161 patients were randomized, 83 to arm 1 and 78 to arm 2. In 62 (10%) patients the protocol was not followed, 12 were lost to follow up after 4 months and in total 34 after 1 year. Of those in early remission 361 (96%) tapered prednisone after 4 months and 200 (53%) tapered MTX after 8 months. After 1 year, remission was achieved in 257 (69%) patients and 119 (32%, 20% of all patients) were in drug free remission.
Patients in arm 1 and 2 achieved remission in similar proportions after 8 months (30 (36%) versus 27 (35%), p=1.0), but after 1 year patients in arm 2 more often achieved remission than in arm 1 (32 (41%) vs 21 (25%), p=0.01). Patients in arm 2 who at 8 months tapered ADA+MTX combination to MTX monotherapy, more often remained in remission after one year than patients tapering poly-DMARDs+prednisone to MTX monotherapy in arm 1 (17/26 (65%) vs 11/30 (37%), p=0.02). After failing to achieve remission on poly-DMARDs+prednisone, 6/24 patients (18%) who switched to ADA achieved remission after one year, compared to 8/27 (30%) who failed on ADA+MTX and increased ADA (p=0.2). Of the total study population 53% were in remission after 1 year. Median (IQR) radiological damage progression after 1 year was 0(0-0) in patients who achieved early remission, and 0(0-0) and 0(0-0) in arms 1 and 2, respectively (p=0.2).
After one year of remission steered combination treatment, 53% of the patients with early arthritis achieved remission. Patients in early remission after initial treatment with MTX and prednisone most often achieved remission after one year (69%) and 32% were in drug free remission. Patients who failed to achieve early remission benefited more from a treatment strategy with adalimumab than with multiple DMARDs+prednisone. In this treat-to-remission cohort, radiological damage progression after 1 year was negligible in all patients.
K. V. C. Wevers-de Boer,
H. K. Ronday,
M. van Oosterhout,
J. H. L. M. Van Groenendael,
A. J. Peeters,
P. B. J. Sonnaville,
B. A. Grillet,
C. F. Allaart,
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ACR Meeting Abstracts - http://acrabstracts.org/abstract/clinical-and-radiological-outcomes-after-one-year-of-remission-steered-combination-treatment-in-patients-with-early-rheumatoid-and-undifferentiated-arthritis/