Background/Purpose: There has been increasing emphasis on intensive treatment of RA but little direct evidence of the impact of such strategies on long term outcome. We evaluated disease activity and outcomes in a prospective observational cohort study over 10 years at a single unit aiming to treat to a target DAS28<2.6.

Methods: We included 1,693 patients seen on 10,773 occasions between 2005 and 2015. At first visit, mean age was 55 years with mean disease duration 10 years. Treatments comprised DMARDs often in combination, and a range of biologics. DAS28, HAQ and quality of life (EQ5D) were recorded at each visit. Temporal changes were assessed by descriptive statistics and maximum likelihood regression models. To further understand outcome in different mean DAS28 categories, we also assessed a subgroup of 714 patients with ³5 follow-up visits between 2010 and 2015 (6728 visits). Mean HAQ, EQ5D and treatment were assessed for each group.

Results: 10 year follow up Mean DAS28 scores fell from 4.1 to 3.7 between 2005 and 2015. Mean HAQ fell from 1.26 to 1.15 and mean EQ5D scores improved from 0.47 to 0.56. Regression models showed annual changes for DAS28 scores were -0.03 (95% confidence intervals -0.04, -0.02), HAQ -0.019 (95% CI -0.025,-0.013) and EQ5D 0.006 (95% CI 0.003, 0.008). The number of patients with high disease activity (DAS28>5.1) decreased from 25% to 16% while DAS28 remission increased from 18% to 27%. The four components of DAS28 showed divergent patterns of change. Mean swollen joint count fell from 3.1 to 2.1 (33%), mean ESR fell from 25 to 18 (26%), and mean tender joint count fell from 5.0 to 4.5 (12%). Mean patient global responses increased by 9% (43.2 to 47.1). Impact of DAS28 category 154/714 (22%) had persistent high disease activity. Compared to patients in remission, HAQ was increased by 1.06, and EQ5D reduced by 0.27. All groups had similar DMARD use, including combination DMARDs. Only 64 (9%) patients with persistent high disease activity were receiving biologics, compared to 18-20% of other groups (P=0.034). This variation results from failure to respond to biologics, an unwillingness to take them, or contraindications to their use.

Conclusion: Intensive management regimens are associated with progressive improvement in disease activity, function and quality of life. Improvements are seen across all strata of disease activity levels with less active disease and more remissions. However, patient global scores do not improve which requires further investigation. A minority of patients have continued high disease activity with substantial disability and reduced quality of life. This group of patients are less likely to receive biologics. Individualised strategies may be required for this group including novel therapies or psychological interventions.