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Abstract Number: 2495

Sex Differences in the Achievement of Remission in Rheumatoid Arthritis – Choice of Disease Activity Measure Matters

Carson Maynard1, Ted R. Mikuls2, Grant W. Cannon3, Bryant R. England4, Gail S. Kerr5, Jennifer Barton6 and Joshua Baker7, 1Division of Rheumatology, Philadelphia VA Medical Center and University of Pennsylvania, PHILADELPHIA, PA, 2Internal Medicine, Division of Rheumatology, VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, NE, 3Division of Rheumatology, Salt Lake City VA Medical Center and University of Utah, Salt Lake City, UT, 4Rheumatology, VA Nebraska-Western Iowa Health Care System & University of Nebraska Medical Center, Omaha, NE, 5Rheumatology, Washington DC VAMC and Georgetown and Howard University, Washington, DC, 6VA Portland Health Care System and Oregon Health and Science, Portland, OR, 7Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Disease Activity and rheumatoid arthritis (RA)

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Session Information

Date: Tuesday, October 23, 2018

Title: Rheumatoid Arthritis – Diagnosis, Manifestations, and Outcomes Poster III: Complications of Therapy, Outcomes, and Measures

Session Type: ACR Poster Session C

Session Time: 9:00AM-11:00AM

Background/Purpose: In rheumatoid arthritis (RA), women may be less likely to achieve clinical remission. These sex differences remain incompletely understood and might relate to differences in performance of disease activity measures, rather than biological sex differences. We evaluated sex differences in remission and low disease activity in patients with RA, comparing composite disease activity measures and definitions.

Methods: This longitudinal cohort study utilized data from the Veterans Affairs Rheumatoid Arthritis registry. Participants fulfilled ACR criteria for RA. Remission and low disease activity were defined based on composite scores (DAS 28 joints with ESR [DAS28-ESR], DAS 28 joints with CRP [DAS28-CRP], clinical disease activity index [CDAI], routine assessment of patient index data 3 [RAPID3]). We also studied achievement of low disease activity based on individual measures applying Boolean and other published criteria (tender joint count 28 joints [TJC28], swollen joint count 28 joints [SJC28], ESR, CRP, physician global assessment [PhGA], patient global assessment [PtGA]). We assessed 1) the likelihood of point remission at any time and 2) the time to sustained remission (2 consecutive visits) among those not in remission at enrollment. Logistic regression models incorporated generalized estimating equations to account for repeated disease activity measures and adjusted for age, race, smoking, and disease duration. Multivariable Cox proportional hazard models assessed differences in the time to sustained remission.

Results: At enrollment, women (n=252, 10.2%) were younger, less likely to be smokers, used less prednisone, and had fewer comorbidities. Considering all points in time, the odds of remission for women were lower only for DAS28-ESR [OR 0.71, (95% CI 0.55, 0.91), p<0.01] (Table 1). In contrast, women were more likely to attain CDAI low disease activity [OR 1.36, (95% CI 1.08, 1.73), p=0.01]. Women were more likely to achieve favorable individual measures- low SJC28, CRP, and PhGA, except for having an ESR <30 mm/hour [OR 0.72, (95% CI 0.57, 0.90), p<0.01]. Using an age-, sex-specific definition, women were more likely to achieve a low ESR [OR 1.32, (95% CI 1.05, 1.64), p=0.02]. In Cox models, women were less likely to reach sustained remission only by DAS28-ESR [HR 0.53, (95% CI 0.35 – 0.80), p<0.01]. There were no significant differences in sustained remission rates using DAS28-CRP, CDAI, or RAPID3.

Conclusion: The comparison of remission rates between men and women varied greatly based on the composite disease activity measure selected. Sex- specific differences in the ESR bias towards lower rates of remission among women using DAS28-ESR. This study suggests selection of disease activity measure may have influenced prior research suggesting low remission rates in women and illustrates the need for sex-specific treatment targets for the DAS28-ESR.

 

Table 1. Odds Ratio of being in remission or low activity for women versus men at any observation adjusted for age, race, smoking, and disease duration.

Remission

Observations

Total n (women)

OR (95% CI)

p-value

   DAS28-ESR (<2.6)

26148

2398 (238)

0.71 (0.55 – 0.91)

<0.01

   DAS28-CRP (<2.6)

24875

2330 (233)

1.14 (0.91 – 1.42)

0.25

   CDAI (≤2.8)

20261

2227 (221)

1.28 (0.96 – 1.71)

0.09

   RAPID3 (≤3)

26261

2348 (231)

0.97 (0.67 – 1.39)

0.85

Low Disease Activity

Observations

Total n (women)

OR (95% CI)

p-value

   DAS28-ESR (≤3.2)

26148

2398 (238)

0.87 (0.71 – 1.08)

0.21

   DAS28-CRP (≤3.2)

24875

2330 (233)

1.19 (0.96 – 1.48)

0.12

   CDAI (≤10)

20261

2227 (221)

1.36 (1.08 – 1.73)

0.01

   RAPID3 (≤6)

26261

2348 (231)

1.04 (0.80 – 1.35)

0.76

Component Measures

Observations

Total n (women)

OR (95% CI)

p-value

   TJC28 (≤1)

28991

2475 (249)

1.07 (0.88 – 1.31)

0.48

   SJC28 (≤1)

28999

2476 (249)

1.51 (1.22 – 1.88)

<0.001

   ESR (<30 mm/hour)

26714

2442 (249)

0.72 (0.57 – 0.90)

<0.01

   ESR (age-, sex- specific)

26714

2442 (249)

1.32 (1.05 – 1.64)

0.02

   CRP (≤1.0 mg/dL)

25196

2366 (243)

1.26 (1.01 – 1.59)

0.04

   PhGA (≤1, 0 to 10 scale)

20363

2238 (222)

1.54 (1.23 – 1.93)

<0.001

   PtGA (≤1, 0 to 10 scale)

28705

2457 (245)

1.22 (0.95 – 1.56)

0.11

Abbreviations: OR= Odds Ratio; DAS28= Disease Activity Score in 28 joints; ESR= Erythrocyte Sedimentation Rate; CRP= C-Reactive Protein; CDAI= Clinical Disease Activity Index; RAPID3= Routine Assessment of Patient Index Data; TJC28= Tender Joint Count in 28 joints; SJC28= Swollen Joint Count in 28 joints; PhGA=Physician Global Assessment; PtGA= Patient Global Assessment

 


Disclosure: C. Maynard, None; T. R. Mikuls, BMS, Ironwood, Horizon, 2,Pfizer, Inc., 5; G. W. Cannon, Amgen Inc., 2; B. R. England, None; G. S. Kerr, Novartis, 2; J. Barton, None; J. Baker, Corrona, Bristol Myers Squibb, 5.

To cite this abstract in AMA style:

Maynard C, Mikuls TR, Cannon GW, England BR, Kerr GS, Barton J, Baker J. Sex Differences in the Achievement of Remission in Rheumatoid Arthritis – Choice of Disease Activity Measure Matters [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/sex-differences-in-the-achievement-of-remission-in-rheumatoid-arthritis-choice-of-disease-activity-measure-matters/. Accessed .
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