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Abstract Number: 2872

Variation in Predictors of Patient and Physician Defined Flares in Rheumatoid Arthritis

Anna O'Connor1, Joshua Baker2, Bryant R. England3, Brian C. Sauer4, Grant W. Cannon5 and J. Steuart Richards6, 1Department of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh, PA, 2Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA, 3Rheumatology, VA Nebraska-Western Iowa Health Care System & University of Nebraska Medical Center, Omaha, NE, 4Salt Lake City VA Medical Center and University of Utah, Salt Lake City, UT, 5Division of Rheumatology, Salt Lake City VA Medical Center and University of Utah, Salt Lake City, UT, 6Pittsburgh VA Medical Center and University of Pittsburgh, Pittsburgh, PA

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Clinical practice, Evaluation, patient outcomes and rheumatoid arthritis (RA)

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Session Information

Date: Tuesday, October 23, 2018

Session Title: 5T108 ACR Abstract: RA–DX, Manifestations, & Outcomes V: Outcomes Measures (2868–2873)

Session Type: ACR Concurrent Abstract Session

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

Background/Purpose: The identification of risk factors associated with flares in RA is challenging because of the use of different composite disease activity scores and a lack of consistency in the definition of a flare. The Clinical Disease Activity Index (CDAI) is a composite disease activity score that incorporates both a patient and evaluator global assessment (PGA and EGA, respectively). We hypothesized that predictors of flares would vary based on the contribution of clinically important worsening of PGA or EGA to the CDAI and identified predictors of RA flare.

Methods:

We utilized data from the Veterans Affairs RA (VARA) registry- a longitudinal multicenter cohort of US veterans who fulfill the 1987 American College of Rheumatology (ACR) criteria for the classification of RA. Only patients with low disease activity (LDA) defined by CDAI score (</=10) were included in analyses. A CDAI flare was defined as an increase in CDAI to >/=10 and change in CDAI of >/=2. PGA and EGA LDA flares were defined as an increase to >10 and a change >/=10 mm in the PGA or EGA. We used multivariable logistic regression incorporating generalized estimating equations to evaluate for independent predictors of flare by the next visit. Covariates tested included age, sex, race, disease duration, smoking status, common comorbidities, sustained low activity, serostatus, current medications, recent medication changes, inflammatory markers, function status (MD-HAQ), and length of interval between visits.

Results:

Data from 1,582 observations with LDA were included [mean age 63 (±11), 90% male, 82% Caucasian, 81% rheumatoid factor (RF) positive]. Predictors of subsequent CDAI flare, EGA flare and PGA flare are outlined in Table 1. Factors associated with subsequent CDAI flare (N=437) included higher tender joint count, swollen joint, and MD-HAQ score. CDAI flare was less likely among those with sustained CDAI LDA at the prior visit. EGA flare (N=505) was associated with the presence of RF, black ethnicity, elevated CRP, and greater TJC. EGA flare was less likely among patients using methotrexate, a sustained LDA by CDAI and higher patient global score. The strongest predictors of PGA flare (N=542) were a greater MD-HAQ score, black ethnicity, and RF positivity.

Conclusion:

Sustained LDA is a strongly associated with a reduced risk of subsequent CDAI flare and EGA flare but not PGA flare. Predictors of increase in both PGA and EGA included black ethnicity and RF positivity. However, while the TJC and CRP predicted EGA flare, the MD-HAQ was the strongest predictor of PGA flare. Understanding the factors that influence evaluator and patient perception of disease flare is important, as this may have implications for treatment decisions.

CDAI flare

(N=437)

Evaluator Global Flare

(N=505)

Patient Global Flare

(N=542)

OR (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

Age

1.00 (0.98-1.01)

NS

1.01 (0.99-1.02)

NS

0.99 (0.98-1.00)

NS

Female sex

0.79 (0.48-1.30)

NS

0.90 (0.56-1.44)

NS

0.60 (0.35-1.03)

NS

Black ethnicity

1.02 (0.73-1.42)

NS

1.45 (1.07-1.96)

*

1.79 (1.25-2.55)

**

Current smoker

1.08 (0.80-1.46)

NS

1.20 (0.91-1.58)

NS

1.07 (0.78-1.49)

NS

RF positive

1.42 (0.97-2.07)

NS

1.62 (1.11-2.35)

*

1.52 (1.05-2.20)

*

CCP positive

0.81 (0.58-1.12)

NS

0.90 (0.65-1.26)

NS

0.57 (0.39-0.82)

**

Nodules

1.40 (0.99-1.96)

NS

1.09 (0.79-1.51)

NS

0.94 (0.66-1.33)

NS

Disease duration

1.01 (1.00-1.02)

NS

1.00 (0.99-1.01)

NS

1.01 (1.00-1.02)

*

Sustained CDAI LDA

0.55 (0.44-0.69)

***

0.64 (0.51-0.81)

***

0.87 (0.69-1.08)

NS

Tender joint count (0-28)

1.23 (1.11-1.35)

***

1.12 (1.02-1.23)

*

1.09 (1.00-1.19)

NS

Swollen joint count (0-28)

1.14 (1.04-1.25)

**

1.04 (0.96-1.13)

NS

0.97 (0.89-1.06)

NS

MD-HAQ

1.68 (1.21-2.34)

**

1.55 (1.13-2.12)

**

2.20 (1.59-3.03)

***

Patient global (0-100mm)

1.01 (1.00-1.02)

**

1.00 (1.00-1.01)

NS

0.96 (0.95-0.97)

***

Physician global score

(0-100mm)

1.02 (1.00-1.03)

**

0.96 (0.95-0.97)

***

1.03 (1.00-1.04)

***

CRP

1.10 (0.96-1.25)

NS

1.16 (1.02-1.32)

*

1.10 (0.96-1.25)

NS

Medications (at flare)

Methotrexate 

0.85 (0.66-1.09)

NS

0.75 (0.59-0.95)

*

0.97 (0.76-1.23)

NS

Prednisone

1.27 (0.94-1.71)

NS

1.19 (0.88-1.62)

NS

1.12 (0.84-1.49)

NS

TNFi

0.88 (0.66-1.16)

NS

0.89 (0.67-1.17)

NS

1.02 (0.76-1.38)

NS

Comorbidities

Depression

1.03 (0.71-1.50)

NS

0.98 (0.72-1.33)

NS

1.47 (1.00-2.16)

NS

Anxiety

1.23 (0.74-2.03)

NS

1.38 (0.86-2.21)

NS

0.80 (0.48-1.34)

NS

Diabetes

1.21 (0.89-1.64)

NS

0.98 (0.72-1.33)

NS

1.18 (0.85-1.62)

NS

COPD

1.12 (0.85-1.47)

NS

1.12 (0.86-1.33)

NS

1.40 (1.07-1.85)

*

Non-obese (BMI 18.0-24.9)

1.37 (0.65-2.89)

NS

1.38 (0.72-2.64)

NS

1.26 (0.58-2.76)

NS

Obesity(BMI 30.0-34.9)

0.76 (0.56-1.02)

NS

1.03 (0.76-1.40)

NS

0.80 (0.59-1.09)

NS

Obesity(BMI 30.0-34.9)

0.76 (0.54-1.06)

NS

1.10 (0.79-1.53)

NS

0.98 (0.69-1.39)

NS

Table 1: Factors associated with subsequent CDAI, EGA or PGA flare from low disease activity. *p<0.05, **p<0.01, ***p<0.001, ns – non-significant

 


Disclosure: A. O'Connor, None; J. Baker, Corrona, Bristol Myers Squibb, 5; B. R. England, None; B. C. Sauer, Amgen Inc., 2; G. W. Cannon, Amgen Inc., 2; J. S. Richards, None.

To cite this abstract in AMA style:

O'Connor A, Baker J, England BR, Sauer BC, Cannon GW, Richards JS. Variation in Predictors of Patient and Physician Defined Flares in Rheumatoid Arthritis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/variation-in-predictors-of-patient-and-physician-defined-flares-in-rheumatoid-arthritis/. Accessed February 6, 2023.
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