Background/Purpose: Treat-to-target is the consensus treatment strategy for patients with rheumatoid arthritis (RA), but supporting evidence for treat-to-target strategy in elderly RA patients in clinical practice is insufficient. The objective of this study was to evaluate structural damage and physical disability of patients who developed RA at ≥60 y/o (elderly onset RA, EORA) and were treated aiming at low disease activity (LDA) in Choju registry of rheumatoid arthritis on non-biologic and biologic disease-modifying antirheumatic drugs (DMARDs) for elderly patients in Japan (CRANE), a prospective, mono-centric registry.

Methods: Of 150 Japanese elderly (≥60 years) patients with RA enrolled in the CRANE, we identified 106 methotrexate-naïve EORA patients with moderate to severe disease activity (disease activity score 28 joints (DAS28)≥ 3.2) and disease duration ≤ 3 years at the enrollment. We analyzed data from 84 patients who completed 12-month follow-up in this study. The treatment was adjusted every 3 months aiming at LDA (DAS28< 3.2). We started treatment with non-biologic DMARD monotherapy (methotrexate (MTX), tacrolimus, salazosulfapyridine, or bucillamine), followed by TNF inhibitors, then tocilizumab or abatacept. The co-primary outcomes were DAS28, Δtotal sharp score (TSS) and Health Assessment Questionnaire-Disability Index (HAQ-DI) at week52.   

Results: Baseline characteristics of the 84 patients were as follows: mean age, 75.3 y/o; mean disease duration, 0.92 years; mean DAS 28, 6.33; mean HAQ, 1.23; anti-CCP antibody positive, 66.3%. Rates for comorbidity of the patients were 33.8% for chronic lung diseases, 12.8% for cardiovascular diseases and16.3% for diabetes mellitus. At week 12, 77.6% and 14.1% of the patients were receiving MTX at 7.3±1.8 mg/week and tacrolimus, respectively. At weeks 24 and 52, 16.9% and 33.3 % of the patients were treated with TNF inhibitors. LDA and functional remission (HAQ-DI≤0.5) were achieved in 29.1% and 42.6% of the patients at week 24, respectively, and in 45.9% and 58.1% at week 52, respectively. Structural remission (ΔTSS/year≤ 0.5) were observed in 39.3 % and rapid radiographic progression (RRP,ΔTSS/year>3) in 32.6% of the patients. Triple (clinical, structural and functional) remission at week 52 was observed in 8.3% of the patients. Mean DAS28 at weeks 0, 12 and 24 and mean HAQ-DI at week 52 was significantly higher in the patients with RRP compared to those without RRP. The multiple logistic regression model involving the area under the curve (AUC) of DAS28 (accumulated DAS28) between week 0 and week 12, as well as age, sex, anti-CCP antibody status, HAQ-DI, and presence of bony erosions at week 0, predicted RRP at week 52 well with the C statistic of 0.897, and the AUC of DAS28 during the first 3 months predicted RRP better than those during the first 6 or 12 months (the C-statistic, 0.879 for 0-6 months, and 0.834 for 0-12 months).

Conclusion: Achieving LDA, structural remission and functional remission in daily clinical practice using non-biologic and biologic DMARDs in EORA patients were realistic goals. Rapid achievement and sustainment of clinical remission is indispensable to prevent RRP in the patients with EORA.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/treat-to-target-strategy-aiming-at-achievement-of-structural-and-functional-remission-in-patients-with-active-elderly-onset-rheumatoid-arthritis/