Background/Purpose: The Treat to Target (TTT) model is well established in the treatment of rheumatic disease. Achieving DAS remission is one of the primary goals of clinicians managing RA. It has become increasingly apparent that the Treat to Target approach is not feasible in all patient subgroups. Rather, patients often enter a low disease activity state but even with modern therapy, cannot achieve TTT remission. The important question is whether low disease activity state is sufficient to prevent joint damage progression. To assess the impact of TTT DAS low disease activity and remission states on MRI and x-ray progression in Rheumatoid Arthritis (RA) in patients treated with Adalimumab and synthetic DMARD’s.

Methods: Single blind, observational radiological outcome study; four sites. Inclusion criteria: RF/CCP positive RA with stable therapy over 6 months. Cohort A: Disease Activity Score (DAS) of < 2.6 on conventional DMARD therapy; Cohort B: DAS score of > 3.2 on Adalimumab therapy; Cohort C: DAS score of < 2.6 on Adalimumab therapy. Participants reviewed every 3-months for 18 months. MRI (T1 GRE and T2 STIR) of the dominant MCP 2-5 / wrist and plain radiographs hands/feet undertaken at baseline and at 18 months. MRI and radiographs were be assessed by one blinded central reader using the RAMRIS score and van der Heijde modification of the Sharp score. Statistical analysis: Differences between Cohorts at baseline were assessed using the Wilcoxon Rank Sum Test. Logistic regression was used to examine associations between radiological progression and cohort, baseline MRI features of synovial thickening, erosion and osteitis.

Results: 110 patients completed the study: 54 in cohort A, 33 in cohort B and 23 in Cohort C. Baseline demographics were similar across all three groups. Cohort A mean age 61, B 58, C 59 years. Disease duration A mean 10 years, B 11 years, C 14 years. The cohorts demonstrated statistically significant differences at baseline for measures of pain, global status, RAPID 3 scores, and Patient Global Assessment (PGA) with no statistically significant differences between XRay and MRI scores at baseline. DAS28 CRP changed in all cohorts, increasing in Cohort A but decreasing in Cohorts B and C. There was no statistically significant difference in Xray progression or MRI measures of progression between the cohorts.

Conclusion: Despite differences in remission status at baseline and taking into account changes in DAS CRP over time, there were no statistically significant differences in radiograph or MRI progression between the three cohorts. This study underscores the need to continue to re-evaluate the Treat to Target approach. Smolen JS,Breedveld FC, Burmester GR,et al. Ann Rheum Dis 2015 annrheumdis-2015-207524

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/real-world-treat-to-target-strategy-in-rheumatoid-arthritis-radiograph-and-mri-outcomes-in-three-cohorts-with-18-month-follow-up/