Background/Purpose: : Despite treatment with tumour necrosis factor inhibitors (TNFi) some rheumatoid arthritis (RA) patients progress radiographically in randomised controlled trials and observational cohorts (1). Risk factors for radiographic progression during TNFi treatment in clinical practice have not been investigated. The aim of this study was to identify baseline risk factors for radiographic progression during 2 years follow-up of TNF-inhibitor treated RA patients in clinical practice.

Methods: X-rays of hands and wrists obtained at the start of TNFi (baseline) and approximately 2 years after (follow-up) were collected from 16 Danish departments, and linked with clinical data from the DANBIO registry. X-rays were blinded to chronology and scored according to the Sharp/van der Heijde method. Potential predictive baseline variables (28-joint Disease Activity Score(DAS28), C-reactive protein(CRP), 28 Swollen Joint Count(SJC), 28 Tender Joint Count(TJC), Health Assessment Questionnaire(HAQ), Total Sharp Score (TSS), age, gender, IgM Rheumatoid Factor (IgM-RF), disease duration, number of previous Disease-Modifying Anti-Rheumatic Drugs (DMARDs), concomitant methotrexate (MTX), concomitant prednisolone, type of TNFi drug) were investigated with univariate regression and significant variables (p < 0.05) included in a logistic regression analysis with +/- radiographic progression (change in TSS> 0) as dependent variable.

Results: 932 patients (75% women, 79% IgM-RF positive, age 57(19-88) years (median(range)); disease duration  6(1-70) years), DAS28 5.4(4.6-6.1) (median(inter-quartile range(IQR)), TSS 30(38) (mean(SD)) 14(2-44)(median(IQR))) had available X-rays. At baseline 59% of patients started treatment with infliximab, 18% with etanercept and 23% with adalimumab. 15% of patients received TNFi monotherapy, 76% combination therapy with MTX and 9% with other DMARDs. At follow-up (median 526, IQR 392-735days), 59% were treated with the initial TNFi, 29% had switched to another TNFi and 12% had withdrawn from TNFi.

Yearly change in TSS was 0.6(2.4) units (mean(SD)), 0.0(0.0-0.5)(median(IQR)). 27% of patients progressed radiographically (change in TSS >0) during TNFi treatment. Independent risk factors for progression were baseline TSS, age, IgM-RF and concomitant treatment with prednisolone (Table).

Table: Final model of logistic regression analysis (n = 932)

Predictors of X-ray progression	Odds Ratio	P value
TSS (pr. unit increase)	1.004	0.049
Age (pr. year increase )	1.03	0.0002
IgM RF (if positive)	1.75	0.006
Concomitant prednisolone (if treated)	1.39	0.03

Conclusion:

In this nationwide observational study of 932 RA patients, baseline TSS, age, IgM-RF and concomitant prednisolone were risk factors for radiographic progression during 2 years follow-up.

References:

(1) Ørnbjerg LM. Ann Rheum Dis Published Online First: 24 April 2012. doi: 10.1136/annrheumdis-2012-201319

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/risk-factors-for-radiographic-progression-during-tnf-inhibitor-treatment-in-932-rheumatoid-arthritis-patients-treated-in-clinical-practice-results-from-the-nationwide-danish-danbio-registry/