Signs of forefeet joint synovitis have a limited impact on patient's perception of rheumatoid arthritis disease activity and acute-phase reactants

Objectives. To determine the prevalence and distribution of signs of synovitis in the residual joints in remission defined by the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) remission criteria and the role of their components in preventing misclassification due to reduced joint count.

Methods. The cross-sectional observational data of RA patients including full joint counts were analyzed. Definitions of remission used were the ACR/EULAR RA remission criteria and their modifications using full joint counts with the same thresholds of the items and the calculated results.

Results. A total of 304 RA patients with 3,149 observations could be analyzed. Patients in remission according to the ACR/EULAR remission criteria can still show residual disease activity in the feet in up to 27% of the population with a 28-joint count remission. Residual disease activity has no impact on patient's global assessment for current disease activity, when signs of concomitant ankle joint synovitis were absent.

Conclusions. RA patients in remission according to the ACR/EULAR definitions can still show signs of synovitis mostly in the forefeet joints. Acute-phase reactants and patient's global assessment for current disease activity have little impact in mitigating the limitation of reduced joint count.     

Predictors of response to anti-TNF therapy according to ACR and EULAR criteria in patients with established RA: results from the South Swedish Arthritis Treatment Group Register

Objective. To identify factors predicting response to firstTNF blocking treatment course in patients with established RAwith a special focus on gender differences. Methods. Patients with active RA initiating their first treatmentcourse of TNF-blocking therapy were enrolled. The study periodwas March 1999 through September 2006. The prospective protocolincluded information on demographics, clinical characteristicsof patients and response measures. Fulfilment of ACR 50–70%improvement and European League Against Rheumatism (EULAR) goodresponse or remission [28-joint disease activity score (DAS28)<2.6] at 3 months were chosen as primary outcome measures.Potential predictors of responses were identified using multivariatebinary logistic regression models. Results. In total, 1565 patients were included in the study.Gender did not influence treatment response. Consistently, concomitantmethotrexate (MTX) was significantly associated with EULAR remission,EULAR good response, ACR50 response and ACR70 response withodds ratios (ORs) 1.97, 2.13, 2.10 and 1.75, respectively. Concurrenttreatment with other DMARDs was also significantly associatedwith EULAR remission, EULAR good response and ACR50 response(OR: 1.96, 2.24 and 1.94, respectively). Likewise, low HAQ atbaseline consistently predicted good clinical outcome. Diseaseactivity at baseline was directly associated with favourableresponse when measured by ACR50 and ACR70 (OR: 1.59 and 1.60,respectively), whereas DAS28 score at baseline was inverselyassociated with EULAR remission (OR: 0.78). Conclusions. In this observational study of patients with establishedRA, gender did not predict response to anti-TNF therapy, whereastreatment with concomitant DMARDs, especially MTX and low disabilitywere associated with good response. Choice of outcome measuresmay influence the predictive value of baseline features. KEY WORDS: Response, Anti-TNF- therapy, Biologics register, Predictors, Rheumatoid arthritis Submitted 10 August 2007; revised version accepted 2 January 2008.     

Allogeneic mesenchymal stem cells transplantation in patients with refractory RA

This study aimed to determine the safety and efficacy of allogeneic mesenchymal stem cells transplantation (MSCT) in refractory rheumatoid arthritis (RA). Four patients with persistently active RA underwent MSCT. The outcome was evaluated by changes in the visual analog scale (VAS 100 mm) pain score, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and 28-joint disease activity score (DAS-28). Three of four patients received a reduction in ESR, DAS-28, and pain VAS score at 1 and 6 months after transplantation. Two of the three had a European League Against Rheumatism (EULAR) moderate response at 6 months but experienced a relapse at 7 and 23 months, respectively. Two patients had no EULAR response to MSCT. No one had achieved the DAS-28-defined remission in the follow-up period. No serious adverse events were reported. Allogeneic MSCT is a safe treatment in severe and resistant RA, but the effectiveness needs to be clarified.     

Treatment response to a second or third TNF-inhibitor in RA: results from the South Swedish Arthritis Treatment Group Register

Objectives. To study treatment response rates of RA patientsundergoing second- and third-line anti-TNF therapy and to identifybaseline predictors of response to second-line treatment. Methods. RA patients monitored in a prospective, observationalstudy, having switched anti-TNF therapy once (first-time switchers,n = 337) or twice (second-time switchers, n = 36)—i.e.following failures with one antibody- and one receptor-typeagent—between March 1999 and December 2006, were studied.Treatment responses at 3 months were assessed by the ACR andEuropean League Against Rheumatism (EULAR) response criteria.Predictive potentials for response to second-line treatmentof demographics, baseline disease activity measures, diseaseand treatment characteristics were analysed using logistic regression. Results. ACR20 response was met by 51% of first-time and 35%of second-time switchers. Corresponding ACR50 rates were 27and 18%; EULAR overall rates (EULAR good or moderate response)71 and 58%; EULAR good rates 25 and 9% and 28-joint diseaseactivity score (DAS28) remission rates 16 and 6%. Identifiedbaseline predictors of response to second-line treatment werelower age and HAQ scores, elevated DAS28 values and having ceasedthe former anti-TNF treatment due to adverse events rather thaninefficacy. No variable was predictive for all examined responsecriteria. Conclusions. Response rates of first-time anti-TNF switchersare somewhat below those of anti-TNF naïve RA patients,while the markedly inferior response rates of second-time switcherssuggest other therapeutic options to be considered in this situation.Identified baseline predictors of response may be useful indicatorsto second-line anti-TNF therapy, but vary depending on the responsecriteria set studied. KEY WORDS: RA, Anti-TNF, Switching, Predictors, Observational study Submitted 29 August 2007; revised version accepted 14 January 2008.     

Comparative validation of clinical disease activity index (CDAI) and simplified disease activity index (SDAI) in rheumatoid arthritis in India

BackgroundCDAI and SDAI have been frequently used to categorize disease activity in patients with rheumatoid arthritis (RA), but have not been comparatively validated in Indian population.ObjectiveTo validate CDAI and SDAI in RA, taking DAS-28 as gold standard and to derive new cutoffs for CDAI and SDAI.MethodsPatients fulfilling ACR/EULAR criteria for diagnosis of RA were studied. After complete history, physical examination and biochemical tests, patients were grouped into remission, low, moderate and high activity on the basis of pre-defined cut-offs for DAS-28, CDAI, and SDAI. Spearman’s correlation and group wise inter-rater agreement tests were performed. Using DAS-28 as gold standard, the sensitivity and specificity of CDAI and SDAI cut off were determined for predicting levels of disease activity by area under receiver operator characteristics curves. (AUROC)ResultsWe studied 112 patients with RA, there was excellent correlation between DAS-28 and CDAI (r = 0.96 with 95% C.I. = 0.94?0.97), CDAI and SDAI (r=0.99, 95% C.I. 0.98?1), and DAS-28 and SDAI (r = 0.96, 95% C.I. = 0.94?0.97). There was a good inter-rater agreement between the various levels of disease activity as defined by DAS-28 and CDAI (weighed k = 0.598) and DAS-28 and SDAI (weighed k = 0.699) with excellent agreement between SDAI and CDAI categories (weighed k = 0.816). There was no statistically significant difference between AUROC of CDAI and SDAI and both performed equally well.ConclusionCDAI and SDAI are highly correlated with DAS-28 score hence are good markers of disease activity. The cut-off values for CDAI and SDAI used in western literature can be used with minor modifications in Indian scenario.     

Clinical remission and/or minimal disease activity in patients receiving adalimumab treatment in a multinational, open-label, twelve-week study

OBJECTIVE: To evaluate the effect of adalimumab treatment on clinical remission and/or minimal disease activity (MDA) in 6,610 patients with active rheumatoid arthritis (RA) who were enrolled in the Research in Active RA trial, a multinational, open-label, 12-week study with an optional extension period. METHODS: Clinical remission was defined as a Disease Activity Score in 28 joints (DAS28)<2.6, Simplified Disease Activity Index (SDAI) score相似文献   

Implementation of a treat‐to‐target strategy in very early rheumatoid arthritis: Results of the Dutch Rheumatoid Arthritis Monitoring remission induction cohort study

Objective

Clinical remission is the ultimate therapeutic goal in rheumatoid arthritis (RA). Although clinical trials have proven this to be a realistic goal, the concept of targeting at remission has not yet been implemented. The objective of this study was to develop, implement, and evaluate a treat‐to‐target strategy aimed at achieving remission in very early RA in daily clinical practice.

Methods

Five hundred thirty‐four patients with a clinical diagnosis of very early RA were included in the Dutch Rheumatoid Arthritis Monitoring remission induction cohort study. Treatment adjustments were based on the Disease Activity Score in 28 joints (DAS28), aiming at a DAS28 of <2.6 (methotrexate, followed by the addition of sulfasalazine, and exchange of sulfasalazine with biologic agents in case of persistent disease activity). The primary outcome was disease activity after 6 months and 12 months of followup, according to the DAS28, the European League Against Rheumatism (EULAR) response criteria, and the modified American College of Rheumatology (ACR) remission criteria. Secondary outcomes were time to first DAS28 remission and outcome of radiography.

Results

Six‐month and 12‐month followup data were available for 491 and 389 patients, respectively. At 6 months, 47.0% of patients achieved DAS28 remission, 57.6% had a good EULAR response, and 32.0% satisfied the ACR remission criteria. At 12 months, 58.1% of patients achieved DAS28 remission, 67.9% had a good EULAR response, and 46.4% achieved ACR remission. The median time to first remission was 25.3 weeks (interquartile range 13.0–52.0). The majority of patients did not have clinically relevant radiographic progression after 1 year.

Conclusion

The successful implementation of this treat‐to‐target strategy aiming at remission demonstrated that achieving remission in daily clinical practice is a realistic goal.

     

Prognostic markers of clinical remission in early rheumatoid arthritis after two years of DMARDs in a clinical setting

OBJECTIVE: To analyze the rate and baseline prognostic factors of clinical remission in a series of patients with early rheumatoid arthritis (RA) after 2 years of therapy based on a structured algorithm using disease-modifying anti-rheumatic drugs (DMARDs) in a clinical setting. To determine whether a good therapeutic response at 6 months of therapy is associated with remission at 2 years. METHODS: One hundred and five patients (81% female) with early RA (disease duration < 2 years) treated with the same therapeutic protocol using gold salts and methotrexate in a step-up strategy, together with methylprednisolone (4 mg/day), were followed up for 2 years. The outcome variable was clinical remission after 2 years of DMARD therapy using the 28-joint disease activity score (DAS28 < 2.6). Clinical, biological, immunogenetic and radiographic data (Larsen score) were analyzed at study entry and after 6, 12, 18 and 24 months of follow-up. Therapeutic response was analyzed using the ACR and EULAR criteria. RESULTS: Remission was observed in 34 patients (32.4%) after 2 years of follow-up. A baseline DAS28 score < 5.1 (p = 0.004), hemoglobin (p = 0.04) and male gender (p = 0.02) were associated with remission in the univariate analysis. In the multivariate logistic regression analysis, only a DAS28 < 5.1 was associated with remission at 2 years (OR 4.1, 95% CI: 1.56;10.77, p = 0.004). The percentage of ACR50 responses after 6 months was significantly higher in patients with remission at 2 years than in those without (66.7% vs 43.3%; p = 0.04). Similar results were obtained when analyzing the good EULAR response (50% vs 20.9%; p = 0.003). Furthermore, when the therapeutic response at 6 months was included in the logistic regression model, only an ACR50 response (OR 3.9, 95% CI 1.14;13.38, p = 0.03) and a good EULAR response (OR 6.23, 95% CI 1.61; 24.04, p = 0.008), but not an ACR20 response or a whole EULAR response were significantly associated with remission. CONCLUSION: In a series of early RA patients treated using a structured algorithm with DMARDs and very low doses of glucocorticoids, clinical remission was observed in one-third of patients after 2 years. Low or moderate disease activity (DAS28 < 5.1) at baseline and a good therapeutic response during the first months of therapy predicts clinical remission at 2 years.     

The discrepancy between clinical and ultrasonographic remission in rheumatoid arthritis is not related to therapy or autoantibody status

To evaluate the clinical remission by means of power Doppler ultrasonographic (PDUS) monitoring in a group of patients with rheumatoid arthritis (RA) in clinical remission (DAS28?<?2.6). The study included 54 patients with RA in therapy with DMARDS, anti-TNF, or no therapy in clinical remission according to ACR criteria and DAS 28?<?2.6 for at least 6?months. All patients had active wrist or hand inflammation in the past. US examination evaluated the presence of active synovitis, power Doppler signal, and synovial hypertrophy on the following bilateral joints: metacarpophalangeal??proximal interphalangeal joints??flexor tendons (on 2°?C3° fingers) and wrist (radiocarpal and midcarpal joints). In 19 patients, there was an agreement between clinical and US parameters. However, 35 patients with clinical remission showed a positive ultrasonographic assessment and at least an active parameter. No statistic correlation was found between US examination and antibody assessment (anti-CCP and/or RF). Patients in therapy with anti-TNF or other therapies showed similar US assessment without significant statistical differences. Among eleven patients that presented swollen and tender joints at the latest physical examination, which preceded US exam, just 5 patients had an US confirmation too. In the other patients, the PDUS did not confirm the presence of inflammation in the corresponding swollen and tender joints or showed a positive ultrasonographic assessment in other locations. The remission state is a great therapy target and not only through the biological therapy. Synovial inflammation could persist independently from type of therapy or autoantibody status.     

Most people over age 50 in the general population do not meet ACR remission criteria or OMERACT minimal disease activity criteria for rheumatoid arthritis

Objective. To analyse the proportion of individuals in the generalpopulation over age 50 who do not meet American College of Rheumatology(ACR) criteria for rheumatoid arthritis (RA) remission, andOMERACT criteria for minimal disease activity (MDA), and tocompare results to RA patients. Methods. A self-report questionnaire was completed by 1400 communitycontrol subjects and 1705 RA patients, including the HealthAssessment Questionnaire (HAQ), gradual rating scales for pain,fatigue and global health, duration of morning stiffness andpainful joints. The prevalence of 4/6 ACR remission criteriaand 4/7 OMERACT criteria for MDA was analysed in community controlsubjects and patients with RA over age 50. Results. For ACR criteria, 76% of control subjects reportedpainful joints, 37% morning stiffness, 62% pain and 66% fatigue,vs 94, 65, 84 and 84% of patients with RA. MDA criteria werenot met by 64% of control subjects for painful joints, 38% forpain, 45% for global health and 18% for HAQ, vs 89, 60, 69 and52% of RA patients. The four ACR remission criteria were metby only 15% of control subjects over age 50 and 3% of RA patients,and MDA criteria by 28% of controls and 7% of patients. Conclusions. The majority of community population over age 50did not meet criteria for remission or MDA in RA. Although aself-report format may differ from results involving an assessor,the current criteria may not be accurate to identify remissionor MDA in people with RA who are older than age 50. KEY WORDS: Rheumatoid arthritis, Remission criteria, Minimal disease activity, Population Submitted 8 November 2006; revised version accepted 7 February 2007.     

Is pre-assessment for anti-TNF therapy in RA necessary in the UK? Analysis of DAS28 in six centres

OBJECTIVES: National Institute for Health and Clinical Excellence (NICE) guidelines for anti-tumour necrosis factor (TNF) in rheumatoid arthritis (RA) state that two pre-assessments of Disease Activity Score (DAS28) should be performed a month apart. We performed a retrospective audit of data from six centres to determine the stability of DAS28 between assessments, and the proportion of patients still satisfying eligibility criteria at baseline. METHODS: All RA patients assessed for anti-TNF from six centres had their pre-assessment DAS28 (DAS-1) compared with their baseline DAS28 (DAS0) using paired t-tests, and a similar analysis for the components of the DAS28. Patients who were no longer eligible for anti-TNF at DAS0 were noted. RESULTS: Six hundred and seventy-nine RA patients showed no significant change in the DAS28, with a mean DAS-1 of 6.74 and DAS0 of 6.73. (P = 0.86). Of the patients, 97.2% fulfilled the UK eligibility criteria at DAS0. Comparison of the individual components of the DAS28 between the two pre-assessment dates showed that there was no significant difference between either the numbers of swollen joints or the erythrocyte sedimentation rate (ESR), but there was a significant increase in the numbers of tender joints of 1.41 (P < 0.001) and in the visual analogue scale (VAS) of 4.22 (P < 0.001). DISCUSSION: The overwhelming majority of patients who fulfil eligibility criteria for anti-TNF drugs 1 month prior to baseline also fulfil the criteria at baseline. There is no significant change in the DAS28 over the month waiting to go onto anti-TNF therapy. A single assessment of the DAS28 would suffice to enable patients to go on to anti-TNF treatment.     

Remission in rheumatoid arthritis: wishful thinking or clinical reality?

OBJECTIVES: To review the concept of remission in rheumatoid arthritis (RA), as defined by the Food and Drug Administration (FDA), the American College of Rheumatology (ACR), and the European League Against Rheumatism (EULAR). To delineate differences between significant clinical improvements, very low disease activity, and the achievement of true remission. To evaluate the prevalence of these outcomes with biologic therapy and traditional disease-modifying antirheumatic drugs (DMARD) regimens. METHODS: The MEDLINE database was searched for the key words "remission" and "rheumatoid arthritis." Efficacy data of RA clinical trials from 1985 to 2004 are based on a literature review of medical journals and abstracts from rheumatology meetings. We review 3 well-defined sets of criteria established by the ACR, EULAR, and the FDA for measuring remission. RESULTS: Defining remissions in clinical trials and clinical practice requires appropriate standardized and objective outcome measures, such as the ACR and EULAR remission criteria. Traditional DMARDs often provide symptom relief, improvements in physical function, and the slowing of radiographic progression in patients with RA, but rarely lead to the complete cessation of RA activity. Remission, as defined by the ACR criteria, has been observed in 7 to 22% of patients treated with traditional DMARD monotherapy (ie, gold, penicillamine, methotrexate [MTX], cyclosporine A, or sulfasalazine), but these remissions have often been short-lived. Treatments with DMARD combinations, biologic monotherapy, and biologic combination therapy with MTX offer greater hope and may facilitate the higher rates of remission. Clinical trial results have shown that newer DMARDs such as leflunomide or the combination of multiple DMARDs can generally elicit greater EULAR remission rates (ranging from 13 to 42%) than monotherapies. Biologic combinations with MTX have also been shown to induce significant remission (as defined by the EULAR criteria) in RA patients, with a 31% rate observed with infliximab plus MTX at 54 weeks, a 50% rate observed for adalimumab plus MTX after 2 years of therapy, and a 41% rate observed for etanercept plus MTX after 2 years of therapy. CONCLUSIONS: In the era of biologics and combination therapy, identifying remission or at least very low disease activity as the ultimate goal in RA therapy should become the new standard for the outcome of all RA trials. The criteria established by the FDA, the ACR, and the EULAR represent an important step toward achieving this goal.     

The relation of hand functions with radiological damage and disease activity in rheumatoid arthritis

The purpose of this study was to investigate specifically the correlation of hand functions determined by Duruoz hand index (DHI) with radiological findings and disease activity in rheumatoid arthritis (RA) patients. Forty-eight RA patients were evaluated with DHI questionnaire, disease activity score (DAS) 28 and modified Larsen scoring method. Correlation between DAS-28 and DHI was assessed in all the patients. Mean DHI scores were compared between patients in remission (DAS-28 < 2.6) and patients who have more or less disease activity (DAS-28 ≥ 2.6). To exclude the probable conflicting effect of disease activity on hand functions, the correlation between radiological scores and DHI was investigated only in patients with remission. There was a positive correlation between DAS-28 and DHI in all patients group (r = 0.434, P < 0.002). No correlation between the radiological scores of any joint groups and DHI could be found in patients with remission. Hand functions seemed to be affected prominently from disease activity. Radiological scores demonstrating joint damage were not in relation with hand functions.     

Methotrexate and hydroxychloroquine combination therapy in chronic chikungunya arthritis: a 16 week study

ObjectiveTo study the clinical profile of patients of chronic chikungunya arthritis presenting to a rheumatology OPD in the Western part of India and to judge the treatment response to the disease modifying drugs (methotrexate and hydroxychloroquine) used to treat them.Materials and methodsThe diagnosis of chronic chikungunya arthritis was based on clinical criteria only. All patients giving a history of fever with arthritis starting during the epidemic of chikungunya in the Western part of India (August–September 2006) and having had the arthritis for > 3 months since then were included in the study. Baseline clinical characteristics were calculated. Most patients received methotrexate (15 to 20 mg weekly) and hydroxychloroquine for their chronic arthritis and their ACR 20, 50 and 70 responses and EULAR remission and EULAR good response based on DAS 28 ESR were calculated.ResultsA total of 305 patients presented to the OPD till March 2008. Mean age of the patients was 49 years. Female to male ratio was 2.8:1 (223:82). The other mean baseline values were: patients global 6 (0 to 10, 0 best), physician's global 5.8 (0 to 10, 0 best), HAQ score 1.6 (0 to 3), swollen joint count 8.8 (28 joint count), tender joint count 14 (28 joint count), ESR 52 mm first hour (Westergren). About one-third of the patients had parasthesias in the carpal tunnel distribution. Rheumatoid factor was positive in 76 out of 256 when it was done (29.7%) and anti-CCP was positive in 6/73 when it was done. Data needed for judging treatment response was available in 149 patients at a mean follow up of 16 weeks period and they received combination of methotrexate and hydroxychloroquine. ACR 20 was achieved in 73/149 (48.9%), ACR 50 in 28/149 (18.8%) and ACR 70 in 6/149 (4%). Only one of the patients achieved EULAR remission (DAS 28 ESR < 2.6) and four others achieved EULAR good response (DAS 28 ESR < 3.2) at the end of 16 weeks. None of the patients had any adverse effect to the DMARDs used.ConclusionChronic chikungunya arthritis is a significant cause of morbidity in this part of the world. In this analysis most patients were middle aged and female to male ratio was 3:1. About one-third of the patients reported carpal tunnel symptoms. About half of the patients who received the combination of methotrexate and hydroxychloroquine achieved an ACR 20 response at 16 weeks.     

Discrepancies between the EULAR response criteria and the NICE guidelines for continuation of anti-TNF therapy in RA: a cause for concern?

OBJECTIVES: A discrepancy exists between the National Institute for Health and Clinical Excellence (NICE) guidelines for continuation of TNF therapy in RA and EULAR response criteria. We performed a retrospective study of patients starting anti-TNF therapy to establish how many NICE non-responders would have met EULAR response criteria, and whether this may increase. METHOD: We calculated the percentage of NICE non-responders who would have met EULAR moderate response criteria. We then compared the mean decrease in disease activity score (DAS28) for patients with low and high baseline scores. We analysed trends for treating RA in Derby with anti-TNF to address whether we were treating less active disease over time. RESULTS: At 3 months (n = 271 patients), 7.7% of NICE non-responders would have met EULAR moderate response criteria. At 6 months (n = 240 patients) this was 23.7%. Patients starting with a higher DAS28 had a significantly greater absolute drop in score. The mean decrease between the 1st and 3rd tertiles of patients divided by baseline DAS28 was significant at 3 and 6 months (P < 0.001). Derby rheumatologists were treating less active RA over time. Comparing the mean DAS28 baseline between the 1st and 3rd tertiles of patients divided by anti-TNF commencement date was significant (P < 0.001). CONCLUSIONS: A significant minority of NICE non-responders would fall within the moderate EULAR response criteria. This is likely to increase in future due to the increasing tendency to initiate anti-TNF in patients with less active disease. Consequently, NICE guidelines should be brought in line with EULAR response criteria.     

The prevalence of patients with rheumatoid arthritis in the West Midlands fulfilling the BSR criteria for anti-tumour necrosis factor therapy: an out-patient study

OBJECTIVES: There are currently two anti-tumour necrosis factor (anti-TNF) therapies licensed for treatment of rheumatoid arthritis (RA). A British Society for Rheumatology (BSR) working party defined criteria for patients that would be suitable for such treatment. The aim of this study was to determine the prevalence of these patients attending rheumatology out-patient departments across the West Midlands. METHODS: Data were collected over a 2-week period in adult out-patient departments of 12 centres. A questionnaire was completed at each patient review. Disease activity scores (DAS-28) were recorded for those who had failed methotrexate treatment and at least one other disease-modifying anti-rheumatic drug (DMARD) in the absence of contraindications to anti-TNF therapy. Information was also collected on the number of DMARDs failed and the use of steroid therapy. RESULTS: A total of 1441 patients with RA were assessed; 177 (12.3%) patients had failed methotrexate and at least one other DMARD. Of these, 19 had contraindications to the use of anti-TNF therapy. In the remaining 158 patients (11%), 80 (5.6%) had a DAS-28 score of >5.1, thus fulfilling BSR criteria for use of anti-TNF therapy. Those with a DAS-28 score of < or = 5.1 were significantly more likely to have been taking steroids compared with those with a DAS-28 score >5.1 (68.2 and 49.3%, respectively, P=0.024). CONCLUSIONS: Of patients with RA attending adult rheumatology out-patient clinics in the West Midlands, 5.6% would meet BSR criteria for use of anti-TNF therapy. Eligibility may be affected by steroid use.     

Comparison of long‐term clinical outcome with etanercept treatment and adalimumab treatment of rheumatoid arthritis with respect to immunogenicity

Objective

To compare rates of sustained low and minimal disease activity and remission according to the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria during 3‐year followup in rheumatoid arthritis (RA) patients treated with etanercept and adalimumab in routine care.

Methods

Four hundred seven RA patients previously unexposed to tumor necrosis factor antagonists were treated with etanercept (n = 203) or adalimumab (n = 204) and assessed at 3‐ and later 6‐month intervals. Treatment allocation was at the discretion of the treating rheumatologist. Clinical parameters were measured at each time point, as were anti‐adalimumab antibodies in adalimumab‐treated patients. Achievement of clinical outcome was defined as the occurrence of sustained (at least 12 consecutive months) low disease activity (28‐joint Disease Activity Score [DAS28] <3.2), minimal disease activity (DAS28 <2.6), or ACR/EULAR remission based on the Simplified Disease Activity Index (SDAI). Non‐overlapping response rates were calculated.

Results

Among the adalimumab group, 13% reached sustained low disease activity but not sustained minimal disease activity, 15% reached sustained minimal disease activity but not sustained remission according to the SDAI, and 16% reached sustained ACR/EULAR remission. In the etanercept group the corresponding rates were 16%, 11%, and 12%, respectively (P = 0.42, overall test for linear trend). Adalimumab‐treated patients without anti‐adalimumab antibodies (n = 150 [74%]) had the best outcomes, and adalimumab‐treated patients with anti‐adalimumab antibodies the worst, with outcomes in etanercept‐treated patients in between (P < 0.0001). Differences were most apparent in the sustained SDAI remission and sustained minimal disease activity categories. For example, 40% of anti‐adalimumab antibody–negative patients, 23% of etanercept‐treated patients, and 4% of anti‐adalimumab antibody–positive patients achieved at least sustained minimal disease activity.

Conclusion

Overall, etanercept and adalimumab treatment appear similar in inducing a good long‐term clinical outcome. However, in the case of adalimumab this is strongly dependent on the presence or absence of anti‐adalimumab antibodies.

     

Evaluation of the preliminary definitions of minimal disease activity and remission in an early seropositive rheumatoid arthritis cohort

OBJECTIVE: To evaluate published proposed definitions of minimal disease activity (MDA) and remission in patients with early rheumatoid arthritis (RA). METHODS: The cohort comprised disease-modifying antirheumatic drug (DMARD)-naive patients with early seropositive active RA (n = 200) treated with traditional DMARDs in the prebiologic era. MDA definitions included Disease Activity Score in 28 joints (DAS28) 相似文献   

Residual disease activity in rheumatoid arthritis patients treated with subcutaneous biologic drugs that achieved remission or low disease activity: a longitudinal observational study

The aim of this study was to evaluate the residual disease activity (RDA) and function in rheumatoid arthritis (RA) patients treated with subcutaneous biologic drugs that achieved a status of remission and low disease activity (LDA) according to the various indices validated for RA and to explore the factors associated with RDA. We consecutively enrolled RA patients that started a new subcutaneous biologic treatment. At baseline and after 3 and 6 months of treatment, we assessed the rate of patients that achieved remission or LDA using the Disease Activity Score on 28 joints, Clinical Disease Activity Index, Simplified Disease Activity Index, and American College of Rheumatology/European League Against Rheumatism remission criteria. The presence of RDA was evaluated as the rate of patients with at least tender joint count >?1, swollen joint count >?1, pain on VAS >?10 mm, general health (VAS) >?10, patient’s disease activity (VAS) >?10, physician disease activity (VAS) >?10, and C reactive protein >?1 mg/dl. We also evaluated the impaired function defined as HAQ score >?0.5. Factors associated to RDA were also investigated. Ninety-three adult patients with RA were enrolled. At 6 months, RDA occurred mostly at the level of Patient’s reported outcome items and less frequently in tender and swollen joints and acute-phase reactants. Interestingly, about one fourth of patients in LDA and up to one fifth of patients in remission had residual functional impairment with an HAQ score greater than 0.5. RDA in RA was present even in patients with remission or LDA, especially for the patient’s reported outcome. Impaired function was also present in a significantly rate of patients.