Background/Purpose: Remission has been proposed as the goal of treatment in patients with early rheumatoid arthritis (RA) by current clinical practice guidelines. Remission is ideal but rare and achieving a low disease activity state (LDA) may be a more realistic goal.The objective of this study was to assess the impact of LDAS at one year on patient function and x-ray progression.

Methods: We used data from The Study Of New Onset Rheumatoid Arthritis (SONORA), a North American prospective cohort of patients with early RA. Our analysis is based on 3 years of follow-up. The Simplified Disease Activity Index (SDAI) and patients’ function (HAQ-DI) were measured at baseline, years 1, 2 and 3.  Hand x-ray was performed yearly up to year 2; a modified sharp score of ≥3.5 indicated important x-ray progression¹.

Multivariate linear regression analysis was performed to assess the impact of reaching LDA (yes/no) at year 1 on future HAQ. Logistic regression was used to assess the impact of reaching LDA at year 1 on x-ray progression (yes/no) at year 2. Both analyses were adjusted for potential clinical confounders. Missing data were imputed using Multiple Imputation.

Results: Baseline characteristics of 984 eligible patients included: mean (sd) age 53 (14.8), disease duration 5.3 (3.1) months, swollen joint count (SJC) 9.4(7.1), tender joint count (TJC) 10.1 (8.0), CRP 1.4 (1.5), SDAI 30.5 (16.6) and median (IQR) HAQ 1.0 (0.37-1.63) and modified Sharp score 3.0 (0.0-7.0). Year 1 LDA was achieved in 37% of patients and x-ray progressed in 17%.Year 1 LDA was strongly associated with lower HAQ at 3 years (p=0.0003). Other predictors included higher baseline HAQ (p<.0001), older age (p=0.002), higher Joint space narrowing (JSN) score (p=0.03) and gender (female) (p=0.007) which were associated with higher HAQ. Complete case and imputed analyses showed similar results. Year 1 LDA was significantly associated with less X-Ray progression at year 2 (OR 0.68, 95% CI 0.47-0.98; p=0.04) in the imputed case analysis (was not significant in complete case analysis).  Baseline Sharp score (1.06, 1.01-1.12; 0.03), positive rheumatoid factor (1.98, 1.2-3.2; 0.01), positive anti-CCP (1.95, 1.1-3.4; 0.03), higher CRP 1.15 (1.01-1.30; 0.03) were also predictors of x-ray progression.

Conclusion: Reaching low disease activity is associated with improved long term outcomes in early RA. This provides strong supports for the current treat to target recommendations. An assessment of prognostic factors at baseline is essential and can help clinicians stratify patients and individualize RA treatment.

Reference:

1-K Bruynesteyn, M Boers, et al. Deciding on progression of joint damage in paired films of individual patients: smallest detectable difference or change. Ann Rhuem Dis.2005 Feb;64(2):179-82

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-impact-of-reaching-low-disease-activity-in-the-first-year-on-future-disability-and-damage-in-patients-with-early-rheumatoid-arthritis/