Background/Purpose: We investigated whether early, remission steered treatment can prevent damage progression in patients with early rheumatoid arthritis (RA) or undifferentiated arthritis (UA), and aimed to identify potential predictive factors for damage progression.

Methods: 610 patients with early RA (2010 criteria) or UA suspected to be early RA started treatment with methotrexate (MTX) and a tapered high dose prednisone in the IMPROVED study. After four months patients achieving a Disease Activity Score (DAS) <1.6 (early remission) tapered prednisone to zero. If remission was maintained at eight months MTX was tapered to zero. Patients not in early remission were randomized to MTX plus hydroxychloroquine, sulphasalazine and prednisone (arm 1) or to MTX plus adalimumab (arm 2). Every four months medication was tapered and next stopped in case of remission but increased or switched in case of no remission. Radiological joint damage was assessed on radiographs of hands and feet at baseline and yearly in random order by two independent readers using the Sharp/van der Heijde score (SHS). Progression scores were compared between treatment arms and between RA and UA patients. Potential predictors of radiological progression were assessed using logistic regression analysis.

Results: Progression scores were available for 488 patients with a median (IQR) SHS progression of 0 (0-0) point. There was no difference in median SHS progression score between RA and UA patients nor between treatment arms. In only 10% (50/488 patients) radiological progression (≥0.5 SHS) was seen: 33/50 (66%) were in the early remission group, 9 (18%) in arm 1, 5 (10%) in arm 2 and 3 (6%) were treated outside the protocol. In 98 patients (7 in the early remission group and 1 in arm 2) the progression score was ≥5 points (minimal clinically important difference) after two years. Age (OR (95% CI) 1.03 (1.00-1.06)) and the combination of anti-CarP (anti-carbamylated protein antibodies) positivity and ACPA (anti-citrullinated protein antibodies) positivity (2.54 (1.16-5.58)) were  independent significant predictors for radiological progression.

Conclusion: After 2 years of remission steered treatment in early arthritis patients radiological progression in the majority of patients was practically zero, regardless of diagnosis RA or UA and regardless of treatment arm following initial combination therapy with methotrexate and a tapered high dose of prednisone. Predictors for radiological progression were age and the combination of anti-CarP positivity and ACPA positivity.

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