Background/Purpose: To evaluate outcomes after 2 years of remission steered therapy in early arthritis patients.

Methods: 610 patients with early rheumatoid or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and tapered high dose of prednisone. Patients in early remission (DAS<1.6) after 4 months, tapered prednisone to zero and when remission persisted after 8 months, also tapered MTX. Patients not in early DAS-remission were randomized to either MTX+hydroxychloroquine+sulphasalazine+prednisone (arm 1) or to MTX+adalimumab (arm2). Based on 4-monthly DAS evaluations, medication was restarted, increased or switched in case of no remission and tapered or stopped in case of remission. Proportions of DAS-remission, drug free remission (DFR) and radiological damage progression (increase Sharp-vanderHeijde Score ≥0.5) were analyzed separately for the treatment strategies and patients with RA and UA.

Results: 387 patients achieved early DAS-remission, 83 patients were randomized to arm 1 and 78 to arm 2 and 50 did not follow the protocol. After 2 years, 301/610 (49%) of all patients were in DAS-remission and 131/610 (21%) in DFR. Of the early remission group, 241/387 (62%) were in DAS-remission and 110/387 (28%) were in DFR. In arm 1, 22/83 (27%) were in DAS-remission compared to 24/78 (31%) in arm 2 (p=0.76), 7/83 (8%) were in DFR in arm 1 and 7/78 (9%) in arm 2 (p=0.90). Remission defined according to the proposed ACR/EULAR remission criteria was achieved in 138/610 (23%) patients; 117/387 (30%) in the early remission group, 2/83 (2%) in arm 1 and 14/78 (18%) in arm 2 (arm 1 vs. 2 p=0.001). There were no significant differences in DAS-remission rates between patients with RA (234/479, 49%) and patients with UA (64/122, 52%) (p=0.25). UA patients more often achieved DFR (41/122 (34%)) than RA patients (89/479 (19%), p<0.001). Over the first 2 years, DAS or HAQ were not significant different between arm 1 and 2 (mean difference (95%CI) DAS 0.01 (-0,2;0,2) and HAQ 0.1 (-0.1;0.2)).Of the total study population, 51/610 (8%) had radiological progression (increase SHS≥0.5), in the early remission group 34/387 (9%) patients showed progression, in arm 1 9/83 (11%) and in arm 2 5/78 (6%) (p arm 1 vs. arm 2=0.31). Median (IQR) SHS progression in all groups was 0 (0-0). 

Conclusion: Patients who achieved early remission after 4 months most often achieved (drug free) remission after 2 years. Patients in arm 1 and 2 achieved lower but comparable (drug free) DAS-remission rates, probably due to remission steered treatment adjustments. This may also explain negligible radiographic damage progression. These results suggest that there is a window of opportunity where effective anti-rheumatic therapy can induce lasting remission and non-progression.

	Early remission n = 387	Arm 1 n = 83	Arm 2 n = 78	p-value arm 1 vs. arm 2
Baseline
Age in years, mean + SD	52 ± 14	49 ± 14	51 ± 14	0.20
Female, n (%)	240 (62)	64 (77)	58 (74)	0.68
ACPA positive, n (%)	225 (58)	40 (48)	37 (47)	0.99
RA(2010), n (%)	298 (77)	66 (80)	66 (85)	0.32
DAS, mean + SD	3.0 ± 0.8	3.6 ± 0.9	3.6 ± 1.0	0.91
HAQ, mean + SD	1.0 ± 0.7	1.4 ± 0.6	1.4 ± 0.6	0.47
Total SHS, median (IQR)	0 (0-0.5)	0 (0-0)	0 (0-0)	0.75
2 years
DAS, mean + SD	1.3 ± 0.8	2.0 ± 0.7	1.9 ± 0.9	0.45
HAQ, mean + SD	0.4 ± 0.5	0.9 ± 0.7	0.8 ± 0.7	0.55
DAS-remission, n (%)	241 (62)	22 (27)	24 (31)	0.76
Drug free remission, n (%)	111 (29)	6 (7)	7 (9)	0.73
ACR/EULAR remission, n (%)	117 (30)	2 (2)	14 (18)	0.001
Total SHS, median (IQR)	0 (0-0.5)	0 (0-1.1)	0 (0-0)	0.12
SHS progression≥0.5, n (%)	34 (9)	9 (11)	5 (6)	0.31

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/clinical-and-radiological-outcomes-of-two-years-remission-steered-treatment-in-early-arthritis-patients/