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Abstract Number: 3184

Is Treat-to-Target Really Working? a Longitudinal Analysis in Biodam

Sofia Ramiro1, Robert B.M. Landewé2, Désirée van der Heijde1, Oliver FitzGerald3, Mikkel Østergaard4,5, Joanne Homik6, Ori Elkayam7, J Carter Thorne8, Margaret Larche9, Gianfranco Ferraccioli10, Marina Backhaus11, Gilles Boire12, Bernard Combe13, Thierry Schaeverbeke14, Alain Saraux15, Maxime Dougados16, Silvano Adami17, Marcello Govoni18, Luigi Sinigaglia19, Alain G. Cantagrel20, Cornelia F. Allaart1, Cheryl Barnabe21, Clifton O. Bingham III22, Paul P. Tak23, Dirkjan van Schaardenburg24, Hilde Berner Hammer25, Rana Dadashova26, Edna Hutchings26, Joel Paschke26 and Walter Maksymowych27, 1Rheumatology, Leiden University Medical Center, Leiden, Netherlands, 2Department of Rheumatology, Amsterdam Rheumatology Center, Amsterdam, Netherlands, 3Rheumatology, St Vincent's University Hospital, Dublin, Ireland, 4Copenhagen Center for Arthritis Research, Copenhagen University Hospital at Glostrup, Glostrup, Denmark, 5Rigshospitalet-Glostrup, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup, Denmark, 6Rheumatology, University of Alberta, Edmonton, AB, Canada, 7Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 8University of Toronto, Toronto, ON, Canada, 9Rheumatology, McMaster University, Hamilton, ON, Canada, 10Rheumatology and Internal Medicine, Catholic University of the Sacred Heart, Rome, Italy, 11Rheumatology/Immunology, Charite University Hospital, Berlin, Germany, 12Department of Medicine/Division of Rheumatology, University of Sherbrooke, Sherbrooke, QC, Canada, 13Department of rheumatology, Lapeyronie Hospital and Montpellier University, Montpellier, France, 14Rheumatology, Pellegrin University Hospital, Bordeaux, France, 15Rheumatology Department, CHU de la Cavale Blanche, Brest Cedex, France, 16Cochin Hospital, Paris Descartes University, Paris, France, 17University of Verona, Verona, Italy, 18University of Ferrara, Ferrara, Italy, 19Department of Rheumatology, Gaetano Pini Institute, Milan, Italy, 20Dept of Rheumatology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France, 21Cumming School of Medicine, University of Calgary, Calgary, AB, Canada, 22Rheumatology, Johns Hopkins University, Baltimore, MD, 23Division of Clinical Immunology and Rheumatology, Amsterdam Rheumatology Center, Amsterdam, Netherlands, 24Rheumatology, Amsterdam Rheumatology and immunology Center, Reade, Amsterdam, Netherlands, 25Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, 26CaRE Arthritis, Edmonton, AB, Canada, 27Department of Medicine, University of Alberta, Edmonton, AB, Canada

Meeting: ACR/ARHP Annual Meeting 2015

Date of first publication: September 29, 2015

Keywords: , ,

Session Information

Date: Tuesday, November 10, 2015

Title: Rheumatoid Arthritis - Clinical Aspects V: Goal = Remission

Session Type: ACR Concurrent Abstract Session

Session Time: 4:30PM-6:00PM

Background/Purpose: A Treat-to-Target approach (T2T), treating patients with RA towards a target, either remission or low disease activity (T2T-REM or T2T-LDA), is nowadays recommended. However it has never been assessed whether such a strategy in daily clinical practice really leads to more patients meeting that target. 

Methods: Two-year data from BIODAM were used. BIODAM is a prospective cohort including RA patients in daily practice from 10 countries, who were started or changed on DMARD and/or anti-TNF treatment and were followed-up every 3 months. Participating physicians were required to practice treat-to-target per protocol. Per visit was decided whether a patient was treated according to T2T-REM or not. The T2T-REM principle was considered met: i) if a patient had already a disease activity score below the target (DAS28-CRP≤2.6) at a certain time point; or ii) if treatment was intensified (by increasing dosage or adding drugs) upon a DAS28>2.6. T2T-LDA was computed using the benchmark for low disease activity (DAS28≤3.2). The main outcome was the presence or absence of ACR/EULAR-boolean remission 3 months after T2T-REM or T2T-LDA. The relationship between T2T and ACR/EULAR Boolean remission 3 months later was investigated using generalized estimating equations with auto-regression.

Results: In total 3084 visits of 539 patients were included (mean (SD) age: 56 (13) years, 76% female, disease duration 6 (8) years, 49% DMARD-naive). In 68% of the visits, T2T-REM was applied (in 79% of the visits T2T-LDA was applied). ACR/EULAR-boolean remission was reached in 15% of the visits, DAS28 remission in 39%, DAS28-LDA in 53%, CDAI remission in 16% and SDAI in 18%. Appropriate application of T2T-REM led to a 52% higher likelihood of ACR/EULAR-boolean remission 3 months later than not applying T2T-REM (OR (95%CI): 1.52 (1.20; 1.93)). Both T2T-REM and T2T-LDA strategies led to lower disease activity (with an exception of DAS28 remission or DAS28-LDA)(see table). Only 9% of the treatment intensifications followed upon a DAS28 between 2.6 and 3.2, and 79% of the intensifications were applied upon a DAS28>3.2. The effect of T2T-REM on ACR/EULAR-boolean remission was stronger in DMARD-naive patients (OR: 2.10 (1.45; 3.03) than in DMARD-experienced patients (OR 1.20 (0.86; 1.66))(P-value for the interaction:<0.05). 

Table – Effect of treat-to-target approach on disease activity outcomes 3 months later

 

 

ACR/EULAR boolean remission

(OR (95% CI))

DAS28 remission

(OR (95% CI))

DAS28-LDA

(OR (95% CI))

CDAI remission

(OR (95% CI))

SDAI remission

(OR (95% CI))

T2T-REM

Unadjusted

1.49 (1.19; 1.86)

0.99 (0.85; 1.15)

1.10 (0.94; 1.29)

1.47 (1.18; 1.83)

1.62 (1.32; 2.00)

Adjusted*

1.52 (1.20; 1.93)

0.96 (0.82; 1.13)

1.09 (0.93; 1.27)

1.49 (1.18; 1.88)

1.62 (1.30; 2.02)

T2T-LDA

Unadjusted

1.95 (1.46; 2.61)

1.37 (1.14; 1.64)

1.30 (1.09; 1.56)

2.24 (1.66; 3.01)

2.53 (1.90; 3.38)

Adjusted*

2.14 (1.56; 2.95)

1.36 (1.12; 1.64)

1.30 (1.08; 1.56)

2.46 (1.77; 3.43)

2.74 (2.00; 3.76)

* Adjusted for age, gender and disease duration

T2T-REM: treat-to-target with remission (DAS28≤2.6) as benchmark; T2T-LDA: treat-to-target with low disease activity (DAS28≤3.2) as benchmark

Conclusion: A treat-to-target approach, even with a modest benchmark (DAS28=3.2), works instantaneously and leads to higher ACR/EULAR-remission rates. T2T is more effective in DMARD-naïve than in DMARD-experienced patients. Rheumatologists should be encouraged to follow a treat-to-target approach in order to improve the outcome of their patients.

Disclosure: S. Ramiro, None; R. B. M. Landewé, None; D. van der Heijde, None; O. FitzGerald, None; M. Østergaard, None; J. Homik, None; O. Elkayam, None; J. C. Thorne, None; M. Larche, None; G. Ferraccioli, None; M. Backhaus, None; G. Boire, None; B. Combe, None; T. Schaeverbeke, None; A. Saraux, None; M. Dougados, None; S. Adami, None; M. Govoni, None; L. Sinigaglia, None; A. G. Cantagrel, None; C. F. Allaart, None; C. Barnabe, None; C. O. Bingham III, None; P. P. Tak, Glaxo Smith Kline, 3; D. van Schaardenburg, None; H. B. Hammer, None; R. Dadashova, None; E. Hutchings, None; J. Paschke, None; W. Maksymowych, None.

To cite this abstract in AMA style:

Ramiro S, Landewé RBM, van der Heijde D, FitzGerald O, Østergaard M, Homik J, Elkayam O, Thorne JC, Larche M, Ferraccioli G, Backhaus M, Boire G, Combe B, Schaeverbeke T, Saraux A, Dougados M, Adami S, Govoni M, Sinigaglia L, Cantagrel AG, Allaart CF, Barnabe C, Bingham CO III, Tak PP, van Schaardenburg D, Hammer HB, Dadashova R, Hutchings E, Paschke J, Maksymowych W. Is Treat-to-Target Really Working? a Longitudinal Analysis in Biodam [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/is-treat-to-target-really-working-a-longitudinal-analysis-in-biodam/. Accessed .

ACR Meeting Abstracts - https://acrabstracts.org/abstract/is-treat-to-target-really-working-a-longitudinal-analysis-in-biodam/