Background/Purpose: Remission in rheumatoid arthritis (RA) arguably is the ultimate goal of an antirheumatic therapy. With modern therapeutic strategies, this goal can be achieved in the majority of patients with early RA (ERA). It is known, that the number and extend of erosions can increase instead of clinically measurable low disease activity or remission (disease activity score in 28 joints; DAS28). We therefore investigated the value of MRI for the detection of erosive changes in patients with DAS28 improvement and/or remission of the German Remission-plus cohort.

Methods: Data-sets of 80 RA patients from the REMISSION-plus study cohort who fulfilled the following criteria were retrospectively analysed: ACR/EULAR 2010 Criteria for RA according to ACR/EULAR criteria, availability of two consecutive MRI scans (low-field MRI, follow up interval 1 year) of the clinically dominant hand and wrist, and the presence of DAS28 (CRP) scores at both time points. The DAS28 was used to assess disease activity. Changes of disease activity were graded by the following classification criteria: DAS28£ 2.6 = clinical remission, £ 3.2 mild disease activity < 5.2 moderate disease activity and > 5.2 severe disease activity. Therapy response was graded by the following improvement criteria proposed by the EULAR committee DAS28 decrease >1.2 units and endpoint score <3.2 =good response, DAS28 decrease >1.2 units and endpoint score >3.2 or DAS28 decrease 0.6 – 1.2 units and endpoint score <5.1 =moderate response, DAS28 decrease <0.6 or DAS28 decrease 0.6 -1.2 units and endpoint score >5.1 =poor response.

Results:   71 of the 80 investigated patients presented a clinical improvement of the DAS28 after 12 month (T4). After 12 months 73% of the 71 patients who improved in DAS28 showed a lower RAMRIS-Score, while 24% demonstrated an increased score despite DAS28 improvement. 34 of the 71 patients who improved in DAS28 reached EULAR Remission. Despite DAS28 remission, 41% of all patients who attained remission showed in increased Erosion-Subscore in MRI after 12 month (T4). Looking at the 71 patients who improved in DAS28 after 12 month, 7 showed EULAR non-response, 19 presented moderate and 45 good EULAR responses. An increase of erosions was found in 71.4% of non-responders 52.6% of moderate responders and 31.1% of good responder at T4 compared to baseline.

Conclusion:   Up to 40% of patients in this study demonstrated a progressive erosive disease course in rheumatoid arthritis detected by MRI despite DAS28 improvement or EULAR remission. These data reflects that DAS28 remission alone might be an insufficient therapy goal in rheumatoid arthritis. MRI should be considered as a secondary outcome measure in interventional therapeutic trials with subsequent observational extension including conventional x-rays to systematically assess this question.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/silent-progression-in-patients-with-rheumatoid-arthritis-is-das28-remission-an-insufficient-goal-in-ra-results-from-the-german-remission-plus-cohort/