Obesity is a risk factor for poor response to treatment in early rheumatoid arthritis: a NORD-STAR study

OBJECTIVE

This report from the NORD-STAR (Nordic Rheumatic Diseases Strategy Trials and Registries) trial aimed to determine if obesity is associated with response to conventional and biological antirheumatic treatment in early rheumatoid arthritis (RA).

METHODS

This report included 793 participants with untreated early RA from the randomised, longitudinal NORD-STAR trial, all of whom had their body mass index (BMI) assessed at baseline. Obesity was defined as BMI ≥30 kg/m2. All participants were randomised 1:1:1:1 to one of four treatment arms: active conventional treatment, certolizumab-pegol, abatacept and tocilizumab. Clinical and laboratory measurements were performed at baseline and at 8, 12, 24 and 48-week follow-up. The primary endpoint for this report was response to treatment based on Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) remission and Disease Activity Score with 28 joints using C-reactive protein (DAS28-CRP) <2.6 stratified by BMI.

RESULTS

Out of 793 people included in the present report, 161 (20%) had obesity at baseline. During follow-up, participants with baseline obesity had higher disease activity compared with those with lower BMI, despite having similar disease activity at baseline. In survival analyses, obesity was associated with a lower likelihood of achieving response to treatment during follow-up for up to 48 weeks (CDAI remission, HR 0.84, 95% CI 0.67 to 1.05; SDAI, HR 0.77, 95% CI 0.62 to 0.97; DAS28-CRP <2.6, HR 0.78, 95% CI 0.64 to 0.95). The effect of obesity on response to treatment was not influenced by the treatment arms.

CONCLUSION

In people with untreated early RA followed up for up to 48 weeks, obesity was associated with a lower likelihood of good treatment response, irrespective of the type of randomised treatment received.

TRIAL REGISTRATION NUMBER

NCT01491815.

Methotrexate Safety and Efficacy in Combination Therapies in Patients With Early Rheumatoid Arthritis: A Post Hoc Analysis of a Randomized Controlled Trial

OBJECTIVE

We investigated methotrexate safety and the influence of dose on efficacy outcomes in combination with three different biologic treatments and with active conventional treatment (ACT) in early rheumatoid arthritis (RA).

METHODS

This post hoc analysis included 812 treatment-naïve patients with early RA who were randomized (1:1:1:1) in the NORD-STAR trial to receive methotrexate in combination with ACT, certolizumab-pegol, abatacept, or tocilizumab. Methotrexate safety, doses, and dose effects on Clinical Disease Activity Index (CDAI) remission were assessed after 24 weeks of treatment.

RESULTS

Compared with ACT, the prevalence of methotrexate-associated side effects was higher when methotrexate was combined with tocilizumab (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.20-1.84) but not with certolizumab-pegol (HR 0.99, 95% CI 0.79-1.23) or with abatacept (HR 0.93, 95% CI 0.75-1.16). With ACT as the reference, the methotrexate dose was significantly lower when used in combination with tocilizumab (β -4.65, 95% CI -5.83 to -3.46; P < 0.001) or abatacept (β -1.15, 95% CI -2.27 to -0.03; P = 0.04), and it was numerically lower in combination with certolizumab-pegol (β -1.07, 95% CI -2.21 to 0.07; P = 0.07). Methotrexate dose reductions were not associated with decreased CDAI remission rates within any of the treatment combinations.

CONCLUSION

Methotrexate was generally well tolerated in combination therapies, but adverse events were a limiting factor in receiving the target dose of 25 mg/wk, and these were more frequent in combination with tocilizumab versus ACT. On the other hand, methotrexate dose reductions were not associated with decreased CDAI remission rates within any of the four treatment combinations at 24 weeks.

Similar levels of disease activity and remission rates in patients with psoriatic arthritis and rheumatoid arthritis-results from the Finnish quality register

OBJECTIVES

To compare the current disease activity and remission rates, and their regional variation in patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA) in Finland.

METHODS

Data of patients' most recent visit in 1/2020-9/2021 were extracted from the Finnish Rheumatology Quality Register. Measures for disease activity and remission included joint counts, DAS28, cDAPSA, CDAI, the Boolean definition, and physician assessment. Regression analyses were applied, adjusted for age and sex.

RESULTS

Data of 3598 patients with PsA (51% female, mean age 54 years) and 13,913 patients with RA (72% female, 74% ACPA-positive, mean age 62 years) were included. The median (IQR) DAS28 was 1.9 (1.4, 2.6) in PsA and 2.0 (1.6, 2.7) in RA (p = 0.94); for cDAPSA, the median (IQR) values were 7.7 (3.1, 14) in PsA and 7.7 (3.3, 14) in RA (p < 0.001). In all regions in both diseases, the median DAS28 was ≤ 2.6 and the median cDAPSA < 13. Remission rates included DAS28 < 2.6 in 73% in PsA and 69% in RA (p = 0.17) and Boolean remission in 17% in PsA and 15% in RA (p < 0.001). By other definitions of remission, the rates ranged between 30% and 46%. Methotrexate was currently used by 49% in PsA and 57% in RA (p < 0.001). Self-administered bDMARDs were currently used by 37% in PsA and 21% in RA (p < 0.001).

CONCLUSION

The overall disease activity was low and similar in patients with PsA and RA across the country. Remission rates varied between 15 and 73%, depending on the definition but were similar in PsA and RA. Key Points • The disease activity and clinical picture was similar between patients with PsA and RA, in a cross-sectional setting in 1.2020-9.2021. • A significant majority of patients with PsA had low disease activity or were in remission according to cDAPSA. Majority of patients with RA were in remission according to DAS28. • Patients with PsA and RA used methotrexate similarly. The utilization of bDMARDs was more prevalent in patients with PsA.

Disease burden measured by patient-reported outcomes: does psoriatic arthritis feel worse than rheumatoid arthritis? A cross-sectional nationwide study

OBJECTIVES

To study the subjective disease burden of patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA), using patient-reported outcomes (PROs) cross-sectionally.

METHODS

Data of 3598 patients with PsA and 13913 with RA were extracted from the database. Measures included the VAS-values of pain, fatigue and patient global assessment (PGA), HAQ, and disease activity at the most recent visit/remote contact in the period 1.2020 to 9.2021. Values were compared between patients with PsA and RA overall, and by sex and age (<50, 50-59, 60-69 and ≥70 years). Regression analyses were applied.

RESULTS

The overall median (IQR)-values for pain were 29 (10, 56) for PsA and 26 (10, 51) for RA, 29 (9, 60) and 28 (8, 54) for fatigue, 28 (10, 52) and 29 (11, 51) for PGA, 0.4 (0, 0.9) and 0.5 (0, 1.0) for HAQ (p<0.001 for all comparisons; adjusted for sex and age). The median (IQR)-values for pain, fatigue, PGA and HAQ were higher for PsA vs. RA in most age groups for males and females. All PROs were higher in older patients with both diagnoses. The median values for DAS28, doctor global assessment, ESR and CRP were 1.9 vs. 2.0, 8 vs. 8, 7 vs. 8 and 2 vs. 3 in PsA and RA, respectively.

CONCLUSIONS

Overall, both PsA and RA groups showed moderate disease control by patients' perspective, but the burden of disease was higher especially in women with PsA compared to RA. Disease activity was similar and low in both diseases.

Commonalities and differences in set-up and data collection across European spondyloarthritis registries - results from the EuroSpA collaboration

BACKGROUND

In European axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) clinical registries, we aimed to investigate commonalities and differences in (1) set-up, clinical data collection; (2) data availability and completeness; and (3) wording, recall period, and scale used for selected patient-reported outcome measures (PROMs).

METHODS

Data was obtained as part of the EuroSpA Research Collaboration Network and consisted of (1) an online survey and follow-up interview, (2) upload of real-world data, and (3) selected PROMs included in the online survey.

RESULTS

Fifteen registries participated, contributing 33,948 patients (axSpA: 21,330 (63%), PsA: 12,618 (37%)). The reported coverage of eligible patients ranged from 0.5 to 100%. Information on age, sex, biological/targeted synthetic disease-modifying anti-rheumatic drug treatment, disease duration, and C-reactive protein was available in all registries with data completeness between 85% and 100%. All PROMs (Bath Ankylosing Spondylitis Disease Activity and Functional Indices, Health Assessment Questionnaire, and patient global, pain and fatigue assessments) were more complete after 2015 (68-86%) compared to prior (50-79%). Patient global, pain and fatigue assessments showed heterogeneity between registries in terms of wording, recall periods, and scale.

CONCLUSION

Important heterogeneity in registry design and data collection across fifteen European axSpA and PsA registries was observed. Several core measures were widely available, and an increase in data completeness of PROMs in recent years was identified. This study might serve as a basis for examining how differences in data collection across registries may impact the results of collaborative research in the future.

Initial presentation of early rheumatoid arthritis

OBJECTIVES

To study the joint distribution and clinical picture of rheumatoid arthritis (RA) at the initial presentation in seropositive (anti-citrullinated protein antibody (ACPA) and/or rheumatoid factor (RF) positive) and negative patients and the effect of duration of symptoms on the clinical picture.

METHODS

Data of patients who received reimbursement for DMARDs for newly diagnosed RA in 1/2019 to 9/2021 were extracted from the national databases. Joint counts, presence of symmetrical swelling, other disease activity measures, and patient reported outcomes (PROs) were compared in seropositive and negative patients. Regression analyses were applied to compare clinical variables in patients with duration of symptoms of <3, 3-6, and >6 months, adjusted for age, sex, and seropositivity.

RESULTS

Data of 1816 ACPA and RF-tested patients were included. Symmetrical swelling was present in 75% of patients. Seronegative versus positive patients had higher value for all disease activity measures and PROs including median swollen joint count (SJC46 10 versus 5) and DAS28 (4.7 versus 3.7), (p<0.001). Patients diagnosed in <3 months had higher median pain VAS (62 versus 52 and 50, p<0.001) and HAQ (1.1 versus 0.9 and 0.75, p = 0.002) compared to those with a duration of symptoms of 3-6 and >6 months. Patients diagnosed >6 months were ACPA-positive more frequently (77% versus 70% in other groups, p = 0.045).

CONCLUSION

Incident RA presents mainly as symmetric arthritis. Seronegative patients have higher disease burden at the initial presentation. Patients experiencing more severe pain and decreased functional ability are diagnosed earlier, regardless of ACPA- status.

The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

BACKGROUND

The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma).

METHODS

Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed.

RESULTS

A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used.

CONCLUSIONS

We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

The validity of rheumatoid arthritis diagnoses in Finnish biobanks

OBJECTIVE

The aim of this study was to determine the validity of rheumatoid arthritis (RA) diagnoses in patients participating in Finnish biobanks.

METHOD

We reviewed the electronic medical records of 500 Finnish biobank participants: 125 patients with at least one visit with a diagnosis of seropositive RA, 125 patients with at least one visit with a diagnosis of seronegative RA, and 250 age- and gender-matched controls. The patients were chosen from five different biobank hospitals in Finland. A rheumatologist reviewed the medical records to assess whether each patients' diagnosis was correct. The diagnosis was compared with the diagnostic codes in the Finnish Care Register for Health Care (CRHC) and special reimbursement data of the Social Insurance Institution of Finland.

RESULTS

The positive predictive value (PPV) of CRHC diagnosis of RA (for seropositive and seronegative RA combined) was 0.82. For patients with a special reimbursement for anti-rheumatic medications for RA, the PPV was 0.89. The PPV was higher in patients with more than one visit. For one, two, five, and 10 visits, the PPV was 0.82, 0.85, 0.89, and 0.90, respectively, and for patients who also had the special reimbursement, the PPV was 0.89, 0.91, 0.93, and 0.94 for one, two, five, and 10 visits, respectively. In patients positive for anti-citrullinated protein antibodies, the PPV was 0.98.

CONCLUSION

These results demonstrate that the validity of RA diagnoses in Finnish biobanks was good and can be further improved by including data on special reimbursement for medication, number of visits, and serological data.

The impact of a csDMARD in combination with a TNF inhibitor on drug retention and clinical remission in axial spondyloarthritis

OBJECTIVES

Many axial spondylarthritis (axSpA) patients receive a conventional synthetic DMARD (csDMARD) in combination with a TNF inhibitor (TNFi). However, the value of this co-therapy remains unclear. The objectives were to describe the characteristics of axSpA patients initiating a first TNFi as monotherapy compared with co-therapy with csDMARD, to compare one-year TNFi retention and remission rates, and to explore the impact of peripheral arthritis.

METHODS

Data was collected from 13 European registries. One-year outcomes included TNFi retention and hazard ratios (HR) for discontinuation with 95% CIs. Logistic regression was performed with adjusted odds ratios (OR) of achieving remission (Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP < 1.3 and/or BASDAI < 2) and stratified by treatment. Inter-registry heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Peripheral arthritis was defined as ≥1 swollen joint at baseline (=TNFi start).

RESULTS

Amongst 24 171 axSpA patients, 32% received csDMARD co-therapy (range across countries: 13.5% to 71.2%). The co-therapy group had more baseline peripheral arthritis and higher CRP than the monotherapy group. One-year TNFi-retention rates (95% CI): 79% (78, 79%) for TNFi monotherapy vs 82% (81, 83%) with co-therapy (P < 0.001). Remission was obtained in 20% on monotherapy and 22% on co-therapy (P < 0.001); adjusted OR of 1.16 (1.07, 1.25). Remission rates at 12 months were similar in patients with/without peripheral arthritis.

CONCLUSION

This large European study of axial SpA patients showed similar one-year treatment outcomes for TNFi monotherapy and csDMARD co-therapy, although considerable heterogeneity across countries limited the identification of certain subgroups (e.g. peripheral arthritis) that may benefit from co-therapy.

Sex differences in remission rates over 24 weeks among three different biological treatments compared to conventional therapy in patients with early rheumatoid arthritis (NORD-STAR): a post-hoc analysis of a randomised controlled trial

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory disease with a well-recognised female preponderance. In this post-hoc analysis of the NORD-STAR trial, we aimed to examine sex differences in remission rates with three different biological treatments combined with methotrexate versus active conventional treatment over 24 weeks, in patients with early rheumatoid arthritis.

METHODS

NORD-STAR was a multicentre, investigator-initiated, assessor-blinded, phase 4, randomised, controlled trial of early rheumatoid arthritis, done in Denmark, Finland, Iceland, Norway, Sweden, and the Netherlands. Newly diagnosed patients, naive to disease-modifying antirheumatic drugs, aged 18 years or older with early rheumatoid arthritis and with a symptom duration less than 24 months were randomly assigned (1:1:1:1) to receive active conventional treatment, certolizumab-pegol, abatacept, or tocilizumab. Sex was reported in case report forms by study physicians or by study nurses. Data on gender were not collected. Remission outcomes were analysed with logistic generalised estimating equations (GEE), using a logit link and exchangeable correlation matrix. The model included treatment, time, sex, and the relevant interactions. For this post-hoc analysis, the co-primary outcomes were differences in Clinical Disease Activity Index (CDAI) remission (CDAI score ≤2·8) between sexes over time and at week 24, assessed with interaction terms (men vs women within each treatment comparison) and using active conventional treatment as the reference. We present adjusted average marginal differences in remission rates (risk differences) with 95% CIs.

FINDINGS

Between Dec 14, 2012, and Dec 11, 2018, 812 patients were enrolled and randomly assigned; 217 received active conventional treatment, 203 received certolizumab-pegol, 204 received abatacept, and 188 received tocilizumab. All 812 patients were included in this analysis; 561 (69%) were women and 251 (31%) were men. Observed CDAI remission rates at 24 weeks were numerically higher among men than among women despite comparable disease activity at baseline (55% vs 50% with active conventional treatment, 57% vs 52% with certolizumab-pegol, 65% vs 51% with abatacept, and 61% vs 40% with tocilizumab). In the adjusted analysis, with active conventional treatment as the reference, the only significant difference between men and women was in the tocilizumab group (pinteraction=0·015); men in the tocilizumab group had a higher probability of CDAI remission, on average over time, than did men in the active conventional treatment group (0·12; 95% CI 0·00 to 0·23), whereas women in the tocilizumab group had a lower probability of remission than did women in the active conventional treatment group (-0·05, 95% CI -0·13 to 0·02).

INTERPRETATION

Numerically higher remission rates were observed in men than in women in all four treatment groups at week 24, suggesting that this generalised sex difference is not related to the treatment. The difference between men and women was significantly greater with tocilizumab, an interleukin (IL)-6 inhibitor, than with active conventional treatment, suggesting a possible additional sex-based effect specific for IL-6 blockade.

FUNDING

None.

Short interruptions of TNF-inhibitor treatment can be associated with treatment failure in patients with immune-mediated diseases

INTRODUCTION

The prevalence of immune-mediated diseases has increased in the past decades and despite the use of biological treatments all patients do not achieve remission. The aim of this study was to characterise the reasons for short interruptions during treatment with two commonly used TNF-inhibitors infliximab and adalimumab and to analyse the possible effects of the interruptions on immunisation and switching the treatment.

MATERIAL AND METHODS

This case-control study was based on retrospective analyses of patient records and a questionnaire survey to clinicians. A total of 370 patients (194 immunised cases and 172 non-immunised controls, 4 excluded) were enrolled from eight hospitals around Finland. Eleven different diagnoses were represented, and the largest patient groups were those with inflammatory bowel or rheumatic diseases.

RESULTS

Treatment interruptions were associated with immunisation in patients using infliximab (p < .001) or adalimumab (p < .000001). Patients with treatment interruptions were more likely to have been treated with more than one biological agent compared to those without treatment interruptions. This was particularly prominent among patients with a rheumatic disease (p < .00001). The most frequent reason for a treatment interruption among the cases was an infection, whereas among the control patients it was remission. The median length of one interruption was one month (interquartile range 1-3 months).

CONCLUSION

Our results suggest that the interruptions of the treatment with TNF-inhibitors expose patients to immunisation and increase the need for drug switching. These findings stress the importance of careful judgement of the need for a short interruption in the biological treatment in clinical work, especially during non-severe infections.

AB0164 ARE PATIENTS WITH RA IN REMISSION IN FINLAND DURING THE COVID TIMES? RESULTS FROM THE FINNISH QUALITY REGISTER

Background

Worries have been expressed, concerning the care of chronic diseases during the Covid times (1).

Objectives

To study the current status of patients with RA in the Finnish quality register database.

Methods

Patients who receive care for RA were identified in the database. Clinical and demographic data from the last visits during 2020-21 were collected, including swollen (SJC46) and tender joint counts (TJC46), doctor assessment of disease activity (Dr global), laboratory tests for inflammatory and serology markers, patient reported outcomes (PROs), and DAS28. Regression models were applied to compare measures of clinical status between the health care regions, adjusted for gender, age, ACPA status, and disease duration.

Results

A total of 14163 patients (72% female, mean (SD) age 62 (14) years, median (IQR) disease duration 8.5 (2.6, 20) years, 84% ACPA positive) were identified. For the entire population, the median (IQR) SJC46 was 0 (0, 1), TJC46 0 (0, 2), ESR 8 (5, 18), CRP 3 (1, 6), and dr global 8 (0, 19). Among PROs, median (IQR) HAQ was 0.5 (0, 1), pain 26 (10, 51), fatigue 28 (8, 54) and patient global 29 (11, 51). Between health care regions, statistically significant differences were found for all variables due to a large sample size. The mean (SD) DAS28 was 2.3 (0.9) for the entire group and 69 % of all patients had DAS28<2.6. The median DAS28 ranged from 2 to 2.7 among health care regions (Figure 1) (p<0.001). Majority of patients were taking csDMARDs only.

Figure 1.

Rheumatoid arthritis in 2020-21: The median DAS28-values in 19 regions in Finland.

Conclusion

The quality register provides comprehensive real-world data on the current status of patients with RA. A majority of patients can be considered being in remission even during the Covid times.

References

[1]Glintborg et al. Rheumatology (Oxford) 2021 Oct 9;60(SI):SI3-SI12

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

POS0077 SEX DIFFERENCES IN EFFECTIVENESS OF FIRST-LINE TUMOR NECROSIS FACTOR INHIBITORS IN PSORIATIC ARTHRITIS; RESULTS FROM THIRTEEN COUNTRIES IN THE EuroSpA RESEARCH COLLABORATION NETWORK

Background

Evidence demonstrates sex differences in disease presentation, physical function, treatment response and drug retention in patients with psoriatic arthritis (PsA). Data from observational cohort studies indicate female sex is associated with reduced effectiveness of tumor necrosis factor inhibitors (TNFis)1,2. Although, conflicting results are also reported3,4. We sought to validate prior studies using data from a large multinational cohort based on real-life clinical practice.

Objectives

To investigate sex differences in treatment response and drug retention rates in clinical practice among patients with PsA, treated with their first TNFi.

Methods

Data from biologic-naïve PsA patients initiating a TNFi in the EuroSpA registries were pooled. In the primary analysis, propensity-score weighting was applied to assess the causal effect of sex on low disease activity (LDA) according to DAS28-CRP at 6 months. A generalized linear regression model was used to estimate the causal risk difference (RD) and relative risk (RR) of sex on LDA. Possible covariates influencing the outcome were determined a priori and selected based on availability in the database (<20% missing). The final covariates included were country, age, conventional synthetic disease-modifying antirheumatic drug use at baseline and TNFi start year. In the secondary analysis, drug retention was assessed over 24 months of follow-up by Kaplan-Meier curves and log-rank test.

Results

In total, 7,679 PsA patients with available data on DAS28-CRP at 6 months were assessed for treatment response. Baseline characteristics are shown in the Table 1. In the adjusted analysis, the probability for females to have LDA was 17% (RR, 0.83; 95% confidence interval [CI], 0.81 to 0.85) lower compared to males and the difference in probability for having LDA was 13 percentage points (RD, 0.13; 95% CI, 0.11 to 0.15). The survival analysis included 18,599 PsA patients with available data on retention rates. The TNFi 6/12/24-month retention rates were significantly lower in females (81%/68%/56%) compared to males (89%/80%/69%), see Figure 1.

Table 1.

Baseline characteristics of all biologic-naïve PsA patients treated with their first TNFi and available DAS28-CRP at 6 month, data pooled across all countries

FemaleMaleMean (SD), median [IQR] or percentagesMean (SD), median [IQR] or percentagesAge (years)49.7 (12.5)47.8 (11.9)Disease duration (years)4.0 [1.0, 10.0]4.0 [1.0, 10.0]TNFi start year 1999-200929%29% 2010-201326%27% 2014-201625%24% 2017-202020%20%Concomittant csDMARD75%77%DAS28-CRP4.4 (1.2)4.2 (1.2)DAPSA2832 (16)29 (16)CRP (mg/L)7.0 [3.0, 17.0]8.0 [3.3, 19.0]SJC (0-28)3.0 [1.0, 6.0]3.0 [1.0, 6.0]TJC (0-28)6.0 [2.0, 10.0]4.0 [2.0, 9.0]VAS pain, mm61 (23)55 (23)VAS fatigue, mm62 (26)53 (27)

Data are as observed, mean (SD), median [IQR] or percentage. TNFi, tumor necrosis factor inhibitor; csDMARD, Conventional synthetic disease-modifying antirheumatic drugs; DAS28-CRP, Disease Activity Score 28-joint count C reactive protein; DAPSA28, Disease Activity in PsA 28; CRP, C-reactive protein; SJC, swollen joint count; TJC, tender joint count.

Conclusion

Treatment efficacy and retention rates are lower among female patients with PsA initiating their first TNFi. Females presented with higher 28-tender joint count and higher scores on patient reported outcomes at baseline, reflecting differences in disease expression. Recognizing these sex differences is of relevance for customized patient care and may improve patient education.

References

[1]Højgaard, et al. Rheumatology (Oxford). 2018 Sep 1;57(9):1651-1660.

[2]Vieira-Sousa, et al. J Rheumatol. 2020 May 1;47(5):690-700.

[3]Kristensen, et al. Ann Rheum. Dis. 2008 Mar;67(3):364-9.

[4]Iervolino, et al. J Rheumatol. 2012 Mar;39(3):568-73.

Acknowledgements

Novartis Pharma AG and IQVIA for supporting the EuroSpA collaboration.

Disclosure of Interests

Pasoon Hellamand Grant/research support from: Novartis, Marleen G.H. van de Sande Speakers bureau: UCB, Consultant of: Abbvie, Eli Lily, Novartis, UCB, Grant/research support from: Novartis, Janssen, UCB and Eli Lilly, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Thomas Klausch: None declared, Nina Trokovic: None declared, Tuulikki Sokka-Isler Consultant of: Abbvie, Amgen, BMS, Celgene, DiaGraphIT, Medac, MSD, Novartis, Orionpharma, Pfizer, Roche, Sandoz, and UCB, Maria Jose Santos Speakers bureau: Abbvie, AstraZeneca, Lilly, Novartis and Pfizer, Elsa Vieira-Sousa Speakers bureau: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Consultant of: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Grant/research support from: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: Novartis, Bente Glintborg Grant/research support from: Pfizer, Abbvie, BMS, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis, Ulf Lindström: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly and Novartis, Brigitte Michelsen Grant/research support from: Novartis, Burkhard Moeller Speakers bureau: MSD, Synergy, Eli Lilly, Bristol-Myers-Squibb, Janssen-Cilag, AbbVie and Pfizer, Raphael Micheroli: None declared, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Corina Mogosan Speakers bureau: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Karin Laas Speakers bureau: Amgen, Janssen, Novartis and Abbvie, Ziga Rotar Speakers bureau: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Consultant of: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Karen Minde Fagerli: None declared, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Consultant of: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Isabel Castrejon Speakers bureau: Lilly, BMS, Janssen, MSD and Abbvie, Consultant of: Lilly, BMS, Janssen, MSD and Abbvie, Manuel Pombo-Suarez Consultant of: Abbvie, MSD and Roche, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, Consultant of: Amgen and Novartis, Thorvardur Love: None declared, Karel Pavelka Speakers bureau: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche and AbbVie, Consultant of: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche and AbbVie, Jakub Zavada Speakers bureau: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis and UCB, Consultant of: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis and UCB, Gökçe Kenar: None declared, Handan Yarkan-Tuğsal: None declared, Merete Lund Hetland Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz and Novartis, Irene van der Horst-Bruinsma Speakers bureau: BMS, AbbVie, Pfizer and MSD, Consultant of: Abbvie, UCB, MSD, Novartis and Lilly, Grant/research support from: MSD, Pfizer, AbbVie and UCB

AB0168 DISEASE BURDEN MEASURED BY PROs: DOES PSORIATIC ARTHRITIS (PsA) FEEL WORSE THAN RHEUMATOID ARTHRITIS (RA)? A CROSS-SECTIONAL STUDY

Background

Little comparative research has been done comparing disease burden between PsA and RA. Previous studies from Nordic countries and the US have shown small differences (0-10/100 VAS units) in patients with PsA vs. RA. The mean and median VAS levels for PsA and RA ranged between 30-40 for pain and 40-50 for fatigue and patient global health in cross-sectional settings (1, 2, 3).

Objectives

To study the current differences in PROs between PsA and RA in Finland.

Methods

3731 patients receiving care for PsA and 14163 for RA were identified in the national quality register for inflammatory arthritides in 2020-21. Patients were divided into groups by sex and age; <50 years, 50-60 years, 60-70 years and ≥70 years. The VAS values of pain, fatigue and patient global health at the most recent visit were compared in PsA vs. RA between the groups. Descriptive statistics and regression models were used for comparison.

Results

Patients with PsA vs RA were younger (mean (sd) age 54(14) vs 62(14)) and less often women (51% vs. 72%). Median (IQR) disease duration after the first symptoms was 8.6 (3.7, 17) years for PsA and 9.5 (3.3, 21) years for RA. The median (IQR) pain was 29 (10, 56) for all patients with PsA and 26 (10,51) for patients with RA. The corresponding values were: fatigue 28 (9, 60) in PsA vs 28 (8, 54) in RA, and patient global health 28 (10, 51) in PsA and 29 (11, 51) in RA.

Median pain was slightly higher in female PsA patients compared to RA patients in all age groups (29 and 18, 35 and 28, 32 and 27 and 48 and 38) (p<0.001). In males, higher levels of pain in PsA vs. RA were seen in age groups older than 50 years old. Figure 1 illustrates the mean (95% CI) pain for PsA and RA in the age and sex groups.

Median fatigue levels were quite similar between the groups. The median patient global health was higher in female PsA compared to RA patients in age groups <50 years and 50-60 years (20 vs. 29 and 30 vs 37) (p<0.001).

Figure 1.

Mean (95 % CI) pain in VAS-units for women and men by age groups in 2020-2021

Conclusion

Female patients with PsA report higher levels of pain in all age groups compared to patients with RA. The same was seen in men >50 years old. Concerning fatigue and patient global health, the differences between PsA and RA were smaller. Compared to earlier research in other countries, disease burden observed by PROs appears lower both in PsA and RA in Finland.

References

[1]Pilgaard T et al. Severity of fatigue in people with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis – Results of a cross-sectional study, PLoS One, 2019; 14(6): e0218831

[2]Egholm CL et al. Discordance of Global Assessments by Patient and Physician Is Higher in Female than in Male Patients Regardless of the Physician’s Sex: Data on Patients with Rheumatoid Arthritis, Axial Spondyloarthritis, and Psoriatic Arthritis from the DANBIO Registry, The Journal of rheumatology, 2015 Oct;42(10):1781-5.

[3]Mease PJ et al. Comparative Disease Burden in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, or Axial Spondyloarthritis: Data from Two Corrona Registries, Rheumatology and therapy, 2019 Dec;6(4):529-542

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

POS0932 UPTAKE OF NEWER BIOLOGIC AND TARGETED SYNTHETIC DMARDs IN PSORIATIC ARTHRITIS, RESULTS FROM FOUR NORDIC BIOLOGIC REGISTRIES

Background

The treatment landscape in psoriatic arthritis (PsA) is changing, including newer biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with different modes of action becoming available. However, the most effective treatment strategy in routine care remains to be established.

Objectives

To explore the uptake and treatment patterns of newer b/tsDMARDs, namely JAK-inhibitors (JAKi; baricitinib, tofacitinib, upadacitinib), IL-17-inhibitors (ixekizumab, secukinumab), abatacept, apremilast, and ustekinumab in PsA patients from the Nordic countries. Furthermore, to describe patient characteristics and extra-musculoskeletal manifestations at treatment start (=baseline).

Methods

Observational cohort study, using prospectively collected routine care data from 4 Nordic rheumatology registries. Treatments (newer b/tsDMARDs with tumor-necrosis-factor inhibitors (TNFi) as the reference) initiated from January 2009 until December 2020 and corresponding baseline patient characteristics were identified. Linkage to national patient registries was used to identify previous extra-musculoskeletal manifestations (0-5 years). Country-level data were pooled for analyses. Uptake of each drug was explored as the cumulative number of treatment starts (a) overall, irrespective of previous b/tsDMARD experience, and (b) in b/tsDMARD-naïve patients. Each patient could contribute >1 treatment course.

Results

Overall, 13,364 unique patients contributing 24,325 treatment courses with either a newer b/tsDMARD (4,855, 20%) or a TNFi (19,470, 80%, whereof 10,897 were started year 2015-20) were identified. For the sub-group of 11,892 first b/tsDMARD treatment courses, 1,009 (8%) were a newer b/tsDMARD (10,883 were a TNFi, whereof 5,956 were started year 2015-20).

Secukinumab dominated the newer b/tsDMARD uptake (1,848 new-starts, Figure 1). Ustekinumab-uptake increased over time both overall and in b/tsDMARD-naïve patients. In b/tsDMARD-naïve patients, apremilast had the fastest uptake (490 new-starts) (Figure 1). Use of JAKi was limited, especially in b/tsDMARD-naïve patients.

Figure 1.

Patients starting a newer b/tsDMARD tended to have longer disease duration and slightly higher disease activity at baseline (DAS28, patient-reported outcomes) than TNFi initiators (Table 1). Previous extra-musculoskeletal manifestations (uveitis, IBD) were rare, and with similar distributions across treatments (Table 1).

Table 1.

Baseline characteristics upon treatment start

Abata-ceptApre-milastBari-citinibIxe-kizumabSecuki-numabTofa-citinibUpada-citinibUste-kinumabAny TNFiCumulative uptake, n3629351063421848494669119470Male gender, %334227384033333744Age54 (12)53 (12)55 (13)52 (13)51 (13)54 (13)52 (10)50 (12)49 (13)b/tsDMARD treatment number, %1952911149020562191512262518171925≥3723378746173836219Disease duration, yrs9 (8)8 (8)10 (8)10 (8)9 (9)11 (10)8 (8)8 (9)7 (8)Pain, VAS (0-100)63 (21)61 (23)64 (23)64 (25)63 (24)66 (23)75 (17)64 (23)59 (24)DAS284.73 (1.34)4.04 (1.35)3.95 (1.36)4.24 (1.19)4.13 (1.36)4.49 (1.33)4.74 (0.88)4.19 (1.32)4.07 (1.29)Uveitis, %*323123022IBD, %*113111-31

Numbers are mean (SD) unless otherwise stated

IBD: inflammatory bowel disease, bDMARD: biologic DMARD, ts: targeted synthetic

*0-5 years previously, available all study period for Iceland, Sweden, Finland until 31Dec2018, not available for Denmark

Conclusion

In this cross-country collaboration we were able to explore uptake of newer b/tsDMARDs. TNFi still dominates compared to newer b/tsDMARDs in routine care treatment of PsA. Newer b/tsDMARDs are mainly used in patients with several previous treatment failures, i.e. with longer disease duration and higher disease activity, indicating difficult to treat disease. Further studies are planned to explore real-world treatment patterns and outcomes.

Acknowledgements

BG and DdiG contributed equally.

Partly funded by NordForsk and Foreum grants. On behalf of the Danish DANBIO, Swedish SRQ, Norwegian NOR-DMARD, Finnish ROB-FIN and Icelandic ICEBIO registries

Disclosure of Interests

Bente Glintborg Grant/research support from: Pfizer, AbbVie, BMS, Daniela Di Giuseppe: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer, Dan Nordström: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz, Novartis., Johan Askling Grant/research support from: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB., Gerdur Gröndal: None declared, Tuulikki Sokka-Isler Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, GSK, Medac, MSD, Novartis, Orion Pharma, Pfizer, Roche, Sandoz, UCB, Sella Aarrestad Provan: None declared, Ulf Lindström: None declared

Cluster analysis identifies unmet healthcare needs among patients with rheumatoid arthritis

Objective: To identify the patterns of healthcare resource utilization and unmet needs of persistent disease activity, pain, and physical disability in rheumatoid arthritis (RA) by cluster analysis.Method: Patients attending the Jyväskylä Central Hospital rheumatology unit, Finland, were, from 2007, prospectively enrolled in a clinical database. We identified all RA patients in 2010-2014 and combined their individual-level data with well-recorded administrative data on all public healthcare contacts in fiscal year 2014. We ran agglomerative hierarchical clustering (Ward's method), with 28-joint Disease Activity Score with three variables, Health Assessment Questionnaire index, pain (visual analogue scale 0-100), and total annual health service-related direct costs (€) as clustering variables.Results: Complete-case analysis of 939 patients derived four clusters. Cluster C1 (remission and low costs, 550 patients) comprised relatively young patients with low costs, low disease activity, and minimal disability. C2 (chronic pain, disability, and fatigue, 269 patients) included those with the highest pain and fatigue levels, and disability was fairly common. C3 (inflammation, 97 patients) had rather high mean costs and the highest average disease activity, but lower average levels of pain and less disability than C2, highlighting the impact of effective treatment. C4 (comorbidities and high costs, 23 patients) was characterized by exceptionally high costs incurred by comorbidities.Conclusions: The majority of RA patients had favourable outcomes and low costs. However, a large group of patients was distinguished by chronic pain, disability, and fatigue not unambiguously linked to disease activity. The highest healthcare costs were linked to high disease activity or comorbidities.

Corrigendum: Adult-Onset Anti-Citrullinated Peptide Antibody-Negative Destructive Rheumatoid Arthritis Is Characterized by a Disease-Specific CD8+ T Lymphocyte Signature

[This corrects the article DOI: 10.3389/fimmu.2020.578848.].

Adult-Onset Anti-Citrullinated Peptide Antibody-Negative Destructive Rheumatoid Arthritis Is Characterized by a Disease-Specific CD8+ T Lymphocyte Signature

Rheumatoid arthritis (RA) is a complex autoimmune disease targeting synovial joints. Traditionally, RA is divided into seropositive (SP) and seronegative (SN) disease forms, the latter consisting of an array of unrelated diseases with joint involvement. Recently, we described a severe form of SN-RA that associates with characteristic joint destruction. Here, we sought biological characteristics to differentiate this rare but aggressive anti-citrullinated peptide antibody-negative destructive RA (CND-RA) from early seropositive (SP-RA) and seronegative rheumatoid arthritis (SN-RA). We also aimed to study cytotoxic CD8+ lymphocytes in autoimmune arthritis. CND-RA, SP-RA and SN-RA were compared to healthy controls to reveal differences in T-cell receptor beta (TCRβ) repertoire, cytokine levels and autoantibody repertoires. Whole-exome sequencing (WES) followed by single-cell RNA-sequencing (sc-RNA-seq) was performed to study somatic mutations in a clonally expanded CD8+ lymphocyte population in an index patient. A unique TCRβ signature was detected in CND-RA patients. In addition, CND-RA patients expressed higher levels of the bone destruction-associated TNFSF14 cytokine. Blood IgG repertoire from CND-RA patients recognized fewer endogenous proteins than SP-RA patients’ repertoires. Using WES, we detected a stable mutation profile in the clonally expanded CD8+ T-cell population characterized by cytotoxic gene expression signature discovered by sc-RNA-sequencing. Our results identify CND-RA as an independent RA subset and reveal a CND-RA specific TCR signature in the CD8+ lymphocytes. Improved classification of seronegative RA patients underlines the heterogeneity of RA and also, facilitates development of improved therapeutic options for the treatment resistant patients.

Active conventional treatment and three different biological treatments in early rheumatoid arthritis: phase IV investigator initiated, randomised, observer blinded clinical trial

OBJECTIVE

To evaluate and compare benefits and harms of three biological treatments with different modes of action versus active conventional treatment in patients with early rheumatoid arthritis.

DESIGN

Investigator initiated, randomised, open label, blinded assessor, multiarm, phase IV study.

SETTING

Twenty nine rheumatology departments in Sweden, Denmark, Norway, Finland, the Netherlands, and Iceland between 2012 and 2018.

PARTICIPANTS

Patients aged 18 years and older with treatment naive rheumatoid arthritis, symptom duration less than 24 months, moderate to severe disease activity, and rheumatoid factor or anti-citrullinated protein antibody positivity, or increased C reactive protein.

INTERVENTIONS

Randomised 1:1:1:1, stratified by country, sex, and anti-citrullinated protein antibody status. All participants started methotrexate combined with (a) active conventional treatment (either prednisolone tapered to 5 mg/day, or sulfasalazine combined with hydroxychloroquine and intra-articular corticosteroids), (b) certolizumab pegol, (c) abatacept, or (d) tocilizumab.

MAIN OUTCOME MEASURES

The primary outcome was adjusted clinical disease activity index remission (CDAI≤2.8) at 24 weeks with active conventional treatment as the reference. Key secondary outcomes and analyses included CDAI remission at 12 weeks and over time, other remission criteria, a non-inferiority analysis, and harms.

RESULTS

812 patients underwent randomisation. The mean age was 54.3 years (standard deviation 14.7) and 68.8% were women. Baseline disease activity score of 28 joints was 5.0 (standard deviation 1.1). Adjusted 24 week CDAI remission rates were 42.7% (95% confidence interval 36.1% to 49.3%) for active conventional treatment, 46.5% (39.9% to 53.1%) for certolizumab pegol, 52.0% (45.5% to 58.6%) for abatacept, and 42.1% (35.3% to 48.8%) for tocilizumab. Corresponding absolute differences were 3.9% (95% confidence interval -5.5% to 13.2%) for certolizumab pegol, 9.4% (0.1% to 18.7%) for abatacept, and -0.6% (-10.1% to 8.9%) for tocilizumab. Key secondary outcomes showed no major differences among the four treatments. Differences in CDAI remission rates for active conventional treatment versus certolizumab pegol and tocilizumab, but not abatacept, remained within the prespecified non-inferiority margin of 15% (per protocol population). The total number of serious adverse events was 13 (percentage of patients who experienced at least one event 5.6%) for active conventional treatment, 20 (8.4%) for certolizumab pegol, 10 (4.9%) for abatacept, and 10 (4.9%) for tocilizumab. Eleven patients treated with abatacept stopped treatment early compared with 20-23 patients in the other arms.

CONCLUSIONS

All four treatments achieved high remission rates. Higher CDAI remission rate was observed for abatacept versus active conventional treatment, but not for certolizumab pegol or tocilizumab versus active conventional treatment. Other remission rates were similar across treatments. Non-inferiority analysis indicated that active conventional treatment was non-inferior to certolizumab pegol and tocilizumab, but not to abatacept. The results highlight the efficacy and safety of active conventional treatment based on methotrexate combined with corticosteroids, with nominally better results for abatacept, in treatment naive early rheumatoid arthritis.

TRIAL REGISTRATION

EudraCT2011-004720-35, NCT01491815.

Multimorbidity among incident Finnish systemic lupus erythematosus patients during 2000-2017

The objective of the study was to examine the risk of other morbidities among patients with systemic lupus erythematosus (SLE). A total of 1006 adult new-onset SLE patients were identified during 1.1.2000- 31.12.2014 from the register of Social Insurance Institution. For each case three general population controls matched according to age, sex and place of residence at the index day were sampled from the population register. Both groups were followed up from the index date until the end of 2017 or until death. The national register on specialized care was explored to gather broadly their 12 organ-specific morbidities, which were found among 91.2% of SLE patients and 66.7% of comparators. The rate ratio (RR) was elevated in almost all disease groups. Musculoskeletal, cardiovascular and genitourinary conditions were the most common comorbidities with RRs of 1.82 (1.68 to 1.97), 1.91 (1.76 to 2.08) and 1.91 (1.73 to 2.09), respectively. Men with SLE had a significantly higher risk for diseases of the genitourinary system and endocrine, nutritional and metabolic diseases compared to women with SLE. The risk of concurrent morbidities is essential to note in the care of SLE patients.

Automated Text Message-Enhanced Monitoring Versus Routine Monitoring in Early Rheumatoid Arthritis: A Randomized Trial

OBJECTIVE

Frequent monitoring of patients with early rheumatoid arthritis (RA) is required for achieving good outcomes. This study was undertaken to investigate the influence of text message (SMS)-enhanced monitoring on early RA outcomes.

METHODS

We randomized 166 patients with early, disease-modifying antirheumatic drug-naive RA to receive SMS-enhanced follow-up or routine care. All patients attended visits at 0, 3, and 6 months, and a follow-up visit at 12 months. Treatment was at the physicians' discretion. The intervention included 13 SMSs during weeks 0-24 with questions concerning medication problems (yes/no) and disease activity (patient global assessment [PtGA], scale 0-10). Patients were contacted if response SMSs indicated medication problems or PtGA exceeded predefined thresholds. Primary outcome was 6-month Boolean remission (no swollen or tender joints and normal C-reactive protein levels). Quality of life (QoL; measured by the Short Form 36 survey) and Disease Activity Score in 28 joints (DAS28) were assessed.

RESULTS

Six and 12-month follow-up data were available for 162 and 157 patients, respectively. In the intervention group, 46% of the patients (38 of 82) reported medication problems and 49% (40 of 82) reported text message PtGAs above the alarm limit. Remission rates at 6 months (P = 0.34) were 51% in the intervention group and 42% in the control group. These rates were 57% and 43% at 12 months (P = 0.17) in the intervention and control groups, respectively. The respective mean ± SD DAS28 scores for the intervention and control groups were 1.92 ± 1.12 and 2.22 ± 1.11 at 6 months (P = 0.09); and 1.79 ± 0.91 and 2.08 ± 1.22 at 12 months (P = 0.28). No differences in QoL were observed.

CONCLUSION

The study did not meet the primary outcome despite a trend favoring the intervention group. This may be explained by the notably high overall remission rates.

OP0018 A MULTICENTER RANDOMIZED STUDY IN EARLY RHEUMATOID ARTHRITIS TO COMPARE ACTIVE CONVENTIONAL THERAPY VERSUS THREE BIOLOGICAL TREATMENTS: 24 WEEK EFFICACY RESULTS OF THE NORD-STAR TRIAL

Background:

The optimal first-line treatment of patients (pts) with early rheumatoid arthritis (RA) is yet to be established.

Objectives:

The primary aim was to assess and compare the proportion of pts who achieved remission with active conventional therapy (ACT) and with three different biologic therapies after 24 wks. Secondary aims were to assess and compare other efficacy measures.

Methods:

The investigator-initiated NORD-STAR trial (NCT01491815) was conducted in the Nordic countries and Netherlands. In this multicenter, randomized, open-label, blinded-assessor study pts with treatment-naïve, early RA with DAS28>3.2, and positive RF or ACPA, or CRP >10mg/L were randomized 1:1:1:1. Methotrexate (25 mg/week after one month) was combined with: 1) (ACT): oral prednisolone (tapered quickly);or: sulphasalazine, hydroxychloroquine and mandatory intra-articular (IA) glucocorticoid (GC) injections in swollen joints <wk 20; 2) certolizumab 200 mg EOW SC (CZP); 3) abatacept 125 mg/wk SC (ABA); tocilizumab 162 mg/wk SC (TCZ). IA GC was allowed in all arms <wk 20. Primary outcome was clinical disease activity index remission (CDAI≤2.8) at wk 24. Secondary outcomes included CDAI remission over time and other remission criteria. Dichotomous outcomes were analyzed by adjusted logistic regression with non-responder imputation (NRI). Non-inferiority analyses had a pre-specified margin of 15%.

Results:

812 pts were randomized. Age was 54.3±14.7 yrs (mean±SD), 31.2% were male, DAS28 5.0±1.1, 74.9% were RF and 81.9% ACPA positive. Fig 1 shows the adjusted CDAI remission rates over time with 95% CI. Table shows crude remission and response rates and absolute differences in adjusted remission and response rates (superiority analysis). Differences in remission and response rates with CZP and TCZ, but not with ABA, remained within the pre-defined non-inferiority margin versus ACT, Fig 2.

Figure 1.

CDAI remission over time (adj. estimates with 95% CI)

Figure 2.

Non-inferiority analysis of protocol population. Estimated differences in CDAI remission rates between Arm 1 (active conventional therapy) and Arms 2, 3, and 4 (biologic arms) as reference with 95% confidence intervals, adjusted for gender, ACPA status, country, age, body-mass index and baseline DAS28-CRP. ABA, abatacept; CZP, certolizumab-pegol; MTX, methotrexate; TCZ, tocilizumab.

Conclusion:

High remission rates were found across all four treatment arms at 24 wks. Higher CDAI remission rate was observed for ABA versus ACT (+9%) and for CZP (+4%), but not for TCZ (-1%). With the predefined 15% margin, ACT was non-inferior to CZP and TCZ, but not to ABA. This underscores the efficacy of active conventional therapy based on MTX combined with glucocorticoids and may guide future treatment strategies for early RA.

Table.

Primary and key secondary outcomes at 24 weeks (ITT)

Active conventional therapy (ACT)Certolizumab+MTXAbatacept+MTXTocilizumab+MTXNo of pts (ITT)200203204188§Crude remission and response ratesCDAI remission42.0%47.8%52.5%41.0%ACR/EULAR Boolean remission34.0%38.4%37.3%31.4%DAS28 remission63.5%68.5%69.6%63.3%SDAI remission41.5%49.8%51.5%42.6%EULAR good response71.5%76.9%79.9%71.3%Difference (95% CI) in rates with Arm 1 as reference (adjusted)CDAI remissionRef4% (-5 to 13%)9% (0.1 to 19%)-1% (-10 to 9%)ACR/EULAR Boolean remissionRef4% (-6 to 13%)5% (-5 to 14%)-4% (-13 to 6%)DAS28 remissionRef3% (-6 to 11%)5% (-4 to 13%)-1% (-10 to 8%)SDAI remissionRef6% (-3 to 18%)9% (-0.3 to 18%)1% (-8 to 11%)EULAR good responseRef4% (-4 to 14%)8% (-2 to 18%)0.4% (-10 to 11%)

§17 patients allocated to Tocilizumab did not receive it due to its unavailability and were excluded from ITT.

Acknowledgments:

Manufacturers provided CZP and ABA.

Disclosure of Interests:

Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD, Anna Rudin Consultant of: Astra/Zeneca, Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Jon Lampa Speakers bureau: Pfizer, Janssen, Novartis, Kim Hørslev-Petersen: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Gerdur Gröndal: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Marte Heiberg: None declared, Jos Twisk: None declared, Simon Krabbe: None declared, Kristina Lend: None declared, Inge Olsen: None declared, Joakim Lindqvist: None declared, Anna-Karin H Ekwall Consultant of: AbbVie, Pfizer, Kathrine L. Grøn Grant/research support from: BMS, Meliha C Kapetanovic: None declared, Francesca Faustini: None declared, Riitta Tuompo: None declared, Tove Lorenzen: None declared, Giovanni Cagnotto: None declared, Eva Baecklund: None declared, Oliver Hendricks Grant/research support from: Pfizer, MSD, Daisy Vedder: None declared, Tuulikki Sokka-Isler: None declared, Tomas Husmark: None declared, Maud-Kristine A Ljosa: None declared, Eli Brodin: None declared, Torkell Ellingsen: None declared, Annika Soderbergh: None declared, Milad Rizk Speakers bureau: AbbVie, Åsa Reckner: None declared, Per Larsson: None declared, Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly and Novartis (not related to the submitted work), Søren Andreas Just: None declared, David Stevens: None declared, Trine Bay Laurberg Consultant of: UCB Pharma (Advisory Board), Gunnstein Bakland Consultant of: Novartis, UCB, Ronald van Vollenhoven Grant/research support from: BMS, GSK, Lilly, UCB, Pfizer, Roche, Consultant of: AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Gilead, Janssen, Pfizer, Servier, UCB, Speakers bureau: AbbVie, Pfizer, UCB

SAT0056 INITIAL PRESENTATION OF RHEUMATOID ARTHRITIS (RA) – IS IT STILL “SYMMETRIC POLYARTHRITIS”?

Background:

RA is traditionally described as a symmetric polyarthritis. The ACR/EULAR 2010 criteria are met if patient has high positive ACPA, symptoms >=6 wks and one small joint swollen. The public and all steps of health care have been informed for many years that RA should be found early.

Objectives:

To study variations in pattern on first presentation of RA.

Methods:

All patients with the new diagnosis of RA were extracted from the GoTreatIT clinical database between 2008 to 2019 at a single RA clinic that covers a population of 250.000. Demographic data, clinical variables, labs, x-rays, joint status and PROs at baseline were included in the analysis. Appropriate parametric/non-parametric tests were used to study differences between groups.

Results:

A total of 1044 (73.5% CCP+) patients with no prior diagnosis of RA were included; 683 (65%) female, mean age 56; 361 (35%) male, mean age 61. At initial presentation in 2008, 60% had >=6 swollen joints (Figure) and a mean DAS28 of 4.4 compared to 22% and 3.8 respectively, in 2019 (p<0.007). Duration of symptoms prior to diagnosis decreased from 6 to 4 months (p=0.033), and the proportion of patients with erosions from 20% in 2008 to 14% in 2019 (ns). Symptoms (PROs) such as pain, fatigue and global health were similar/slightly worse in 2019 compared to 2008.

Conclusion:

RA cannot be marketed as “symmetric polyarthritis”, as more than half of the patients have a maximum of 2 swollen joints at the time of the diagnosis at the most recent years. Patients with RA can be identified earlier, with less disease activity and damage, compared to previous years.

Figure:

Disclosure of Interests:

None declared

THU0482 PAIN CATASTROPHIZING AND DISEASE PERCEPTION DIFFERS BETWEEN NORWEGIAN AND FINNISH OUTPATIENT CLINIC PSORIATIC ARTHRITIS PATIENTS DESPITE COMPARABLE OUTCOMES ON OBJECTIVE MEASURES OF DISEASE

Background:

Pain catastrophizing (the tendency to describe a pain experience in more exaggerated terms than the average person, to ruminate on it more, or to feel more helpless about it), has been associated with reduced likelihood of achieving remission in rheumatoid arthritis patients (1). Cultural and societal differences between countries may have an impact on outcome such as patients’ perceptions of disease.

Objectives:

To compare patient pain catastrophizing, patient perception of disease, objective measures of disease and treatment in psoriatic arthritis (PsA) patients between a Norwegian and a Finnish outpatient clinic. Further, to explore for associations with pain catastrophizing.

Methods:

All PsA patients followed at the outpatient clinics are routinely monitored using a structured medical support system (GoTreatIT® Rheuma). Data collection, done in 2018-19 is listed in the table.

Patients reported their pain catastrophizing answering the two questions, “When I feel pain it is terrible and I feel it is never going to get any better. When I feel pain, I can’t stand it anymore.” Each question is scored 0-6 and mean value of both is calculated. Pain catastrophizing was defined if mean score ≥4.

Categorical variables were presented as numbers (%) and continuous variables as mean (SD) and associates explored using univariate and multivariate analysis.

Results:

A total of 302 Finnish and 363 Norwegian PsA patients were examined. Pain catastrophizing was reported significantly less commonly among the Finnish as compared to the Norwegian PsA clinic patients, both expressed as mean (SD) values (1.48 (1.42) vs 2.05 (1.42), p<0.001) and proportions of patients having a score ≥4 (7.6% (n=23) vs 12.5% (n=45), p=0.043, respectively). As shown in the table the Finnish patients had significantly more years of education, shorter disease duration and less pain and fatigue than the Norwegian patients. For the other features, no significant differences between the two cohorts were found.

Finland (n=302)Norway (n=363)PAge, years54.0 (13.3)54.7 (12.5)0.49Females153 (50.7%)181 (49.9%)0.84BMI. Kg/m228.8 (5.6)28.1(5.1)0.06Current smoking44 (14.6%)51 (14.1%)0.86Education, years13.6 (3.5)12.7 (3.8)0.001Disease duration, years4.7 (4.3)9.9 (8.9)<0.001CRP, mg/L4.3 (6.8)4.0 (8.8)0.69MDglobal assessment, VAS 0-100 mm6.84 (1.29)5.71 (8.50)0.1928 swollen joint count0.48 (1.35)0.31 (1.16)0.1428 tender joint count1.01 (2.83)1.37 (2.80)0.14DAPSA9.66 (8.95)11.33 (9.60)0.06Pain, VAS 0-100 mm30.73 (25.92)35.55 (25.76)0.023Fatigue, VAS 0-100 mm29.96 (29.24)42.56 (31.94)<0.001MHAQ, 0-30.39 (0.44)0.43 (0.41)0.24Body surface area for psoriasis2.45 (8.15)2.66 (6.15)0.17Current b-tsDMARDs121 (40.1%)139 (38.3%)0.64

In univariate analyses female gender, higher BMI, less years of education, Dr. global, tender joint count, DAPSA, pain, fatigue, MHAQ and psoriasis body surface area were found to be associated with more pain catastrophizing.

In multivariate analysis (mandatory adjusting for age, gender, BMI, years of education and disease duration) fewer years of education, higher scores for pain, fatigue and MHAQ and being patient at the Norwegian center were independently associated with more pain catastrophizing.

Conclusion:

Our data indicate that cultural differences across countries may have a significant impact on outcomes that reflecting patients’ perceptions of disease. This may have an implication when merging heterogeneous databases across countries.

References:

[1]Hammer HB et al. Arthritis Care Res 2018;70:703-12.

Disclosure of Interests: :

Glenn Haugeberg: None declared, Inger Johanne Widding Hansen: None declared, Hilde Berner Hammer: None declared, Arthur Kavanaugh Grant/research support from: Abbott, Amgen, AstraZeneca, BMS, Celgene Corporation, Centocor-Janssen, Pfizer, Roche, UCB – grant/research support, Brigitte Michelsen: None declared, Kirsi Paalanen: None declared, Tuulikki Sokka-Isler: None declared

AB1251 VALIDITY OF RHEUMATOID ARTHRITIS DIAGNOSES IN FINNISH BIOBANK PATIENTS

Background:

Finnish healthcare registers are used in medical research, but there is little data about the validity of these registers in rheumatology.

Objectives:

The aim of our study was to determine the validity of rheumatoid arthritis (RA) diagnoses in patients participating in the Finnish Biobanks.

Methods:

We reviewed the electronic patient charts of 125 patients with at least one visit with a diagnosis of seropositive RA, 125 patients with at least one visit with a diagnosis of seronegative RA and 250 age-and-sex matched controls. Patients were randomly selected from Finnish biobank participants. We evaluated whether the patients’ diagnosis of RA recorded in the hospital discharge registry at the participating hospital was correct according to chart review and expert opinion. In the control group it was investigated whether the diagnosis of RA was written in the patients’ chart, but the diagnosis code was not recorded.

Results:

The positive predictive value (PPV) of a single hospital registry diagnosis of seropositive RA was 0.74 but rose to 0.98 in patients with a special reimbursement for seropositive RA and 0.98 in anti-citrullinated protein antibody positive patients. For seronegative RA, the PPV of a diagnosis was 0.72 and in patients with a special reimbursement for seronegative RA 0.89. The PPV was higher in patients with more than one visit with the diagnosis: 0.92 if the patients had at least 5 visits with seropositive RA and 0.88 with at least 5 visits with seronegative RA. Negative predictive value for RA diagnosis was 0.99.

Conclusion:

These results demonstrate that the validity of RA diagnoses in healthcare registers can be markedly improved with data about special reimbursement for medication, number of visits and serological data.

Disclosure of Interests:

Antti Palomäki Consultant of: Pfizer, Speakers bureau: Pfizer, Sanofi, MSD, Johanna Paltta Consultant of: Lilly, Abbvie, Laura Pirilä Consultant of: Novartis, MSD Finland, Roche, Bristol-Myers-Squibb, Pfizer, Sanofi, Abbvie, Oy Eli LIlly Finland Ab, UCB Pharma Oy Finland, Jansen-Cilag, Mylan, Sandoz, Boehringer-Ingelheim, Paid instructor for: Boehringer -Ingelheim, MSD Finland, Speakers bureau: Boehringer-Ingelheim, Pfizer Finland, Hanna-Kaisa Heikkilä: None declared, Pia Isomäki Consultant of: Abbvie, BMS, Eli Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, Johanna Huhtakangas Consultant of: Boehringer Ingelheim, Tuulikki Sokka-Isler: None declared, Oili Kaipiainen-Seppänen Speakers bureau: Boehringer Ingelheim, Kari Eklund Consultant of: Celgene, Lilly, Speakers bureau: Pfizer, Roche

Patients with rheumatic diseases share similar patterns of healthcare resource utilization

Objectives: Healthcare service needs have changed with the use of effective treatment strategies. Using data from the modern era, we aimed to explore and compare health service-related direct costs in juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and axial spondyloarthritis (AxSpA). Methods: We linked a longitudinal, population-based clinical data set from Finland's largest non-university hospital's rheumatology clinic with an administrative database on health service-related direct costs in 2014. We compared all-cause costs and costs of comorbidities between adult patients with JIA, PsA, RA, and AxSpA (including ankylosing spondylitis). We also characterized patients with high healthcare resource utilization. Results: Cost distributions were similar between rheumatic diseases (p = 0.88). In adulthood, patients with JIA displayed a similar economic burden to much older patients with other inflammatory rheumatic diseases. A minority were high utilizers: among 119 patients with JIA, 15% utilized as much as the remaining 85%. For PsA (213 patients), RA (1086), and AxSpA (277), the high-utilization proportion was 10%. Both low and high utilizers showed rather low disease activity, but in high utilizers, the patient-reported outcomes were slightly worse, with the most distinct differences in pain levels. Of health service-related direct costs, index rheumatic diseases comprised only one-third (43.6% in JIA) and the majority were comorbidity costs. Conclusions: Patients with JIA, PsA, RA, and AxSpA share similar patterns of healthcare resource utilization, with substantial comorbidity costs and a minority being high utilizers. Innovations in meeting these patients' needs are warranted.

Healthcare costs and outcomes in adult patients with juvenile idiopathic arthritis: a population-based study

OBJECTIVES

Evidence of the economic burden and long-term outcomes of juvenile idiopathic arthritis (JIA) remains scarce. Our aim was to explore healthcare costs and long-term outcomes in adult patients with JIA.

METHOD

We identified all adult patients (≥ 18 years) with JIA who visited Jyväskylä Central Hospital rheumatology unit between May 2007 and March 2016. We considered individual medians of time-dependent clinical variables. These data were linked to administrative data from the area from the fiscal year 2014, which include information on all public healthcare contacts. Healthcare utilization is presented as direct costs in euros (EUR). Factors affecting direct costs were assessed with a generalized linear model.

RESULTS

In 218 patients, median 28-joint Disease Activity Score with three variables (DAS28-3) was < 2.6 in 88.6% in those aged < 30 and in 72.9% in those aged ≥ 30 years, and median Health Assessment Questionnaire (HAQ) score was < 0.5 in 85.7% and 45.4%, respectively. In the utilization data (four municipalities, 137 patients), the total annual health services-related direct costs were 432 257 EUR (mean = 3155 EUR/patient/year). Thirty-six patients (26.3%) used biological disease-modifying anti-rheumatic drugs (bDMARDs) in 2014 for a total of 355 months, and the annual cost of bDMARDs was estimated at 355 000 EUR. Those with active disease had mean costs 2.4-fold higher than those with low or no disease activity. A one-point increase in median raw HAQ incurred an average 228 EUR increase in annual costs (p = 0.03).

CONCLUSION

Most adult patients with JIA seem to manage well with their arthritis, bearing in mind that there still is room for improvement in long-term outcomes.

Long-Term Increase of Radiographic Damage and Disability in Patients with RA in Relation to Disease Duration in the Era of Biologics. Results from the SCQM Cohort

Objectives: There is little information on the relation between disease duration, disability and radiographic outcome since the introduction of biologics into the therapy of rheumatoid arthritis (RA). No long -term cohort studies have been conducted on this subject so far. To analyse radiographic damage, disability, and disease activity in RA-patients dependent on disease duration in the Swiss national RA cohort (SCQM). Methods: The primary outcome was the association between the radiographic destruction, assessed by Ratingen scores, and disease duration. All patients with at least one clinical visit were analysed with polynomial and multiple negative binomial models. Results: The disease duration in the 8678 patients with available radiographs analysed ranged between less than 1 and more than 65 years (median 8.3). Disease duration and radiographic destruction were significantly associated with an average increase of Ratingen scores by 8.3% per year. Apart from disease duration, positive rheumatoid factor was the strongest predictor for radiographic destruction. While DAS28-scores remained stable in patients with a disease duration of more than 5 years (median DAS28 2.8), HAQ-DI scores increased continuously by 0.018 for each additional year. Conclusion: In this RA cohort, patients show a continuous increase of articular destruction and physical disability in parallel with disease duration. Even when nowadays a satisfactory control of disease activity can be achieved in most patients, RA remains a destructive disease leading to joint destruction and physical disability in many patients.

Somatic STAT3 mutations in Felty syndrome: an implication for a common pathogenesis with large granular lymphocyte leukemia

Felty syndrome is a rare disease defined by neutropenia, splenomegaly, and rheumatoid arthritis. Sometimes the differential diagnosis between Felty syndrome and large granular lymphocyte leukemia is problematic. Recently, somatic STAT3 and STAT5B mutations were discovered in 30–40% of patients with large granular lymphocyte leukemia. Herein, we aimed to study whether these mutations can also be detected in Felty syndrome, which would imply the existence of a common pathogenic mechanism between these two disease entities. We collected samples and clinical information from 14 Felty syndrome patients who were monitored at the rheumatology outpatient clinic for Felty syndrome. Somatic STAT3 mutations were discovered in 43% (6/14) of Felty syndrome patients with deep amplicon sequencing targeting all STAT3 exons. Mutations were located in the SH2 domain of STAT3, which is a known mutational hotspot. No STAT5B mutations were found. In blood smears, overrepresentation of large granular lymphocytes was observed, and in the majority of cases the CD8⁺ T-cell receptor repertoire was skewed when analyzed by flow cytometry. In bone marrow biopsies, an increased amount of phospho-STAT3 positive cells was discovered. Plasma cytokine profiling showed that ten of the 92 assayed cytokines were elevated both in Felty syndrome and large granular lymphocyte leukemia, and three of these cytokines were also increased in patients with uncomplicated rheumatoid arthritis. In conclusion, somatic STAT3 mutations and STAT3 activation are as frequent in Felty syndrome as they are in large granular lymphocyte leukemia. Considering that the symptoms and treatment modalities are also similar, a unified reclassification of these two syndromes is warranted.

Clinical trials of new drugs for the treatment of rheumatoid arthritis: focus on early disease

The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases convened a task force of experts in rheumatoid arthritis (RA) and clinical trial methodology to comment on the new draft ‘Guideline on clinical investigation of medicinal products for the treatment of RA’ released by the European Medicines Agency (EMA). Special emphasis was placed by the group on the development of new drugs for the treatment of early RA. In the absence of a clear definition of early RA, it was suggested that clinical investigations in this condition were conducted in disease-modifying antirheumatic drugs naïve patients with no more than 1 year disease duration. The expert group recommended using an appropriate improvement in disease activity (American College of Rheumatology (ACR) or Simplified/Clinical Disease Activity Index (SDAI/CDAI) response criteria) or low disease activity (by any score) as primary endpoints, with ACR/European League Against Rheumatism remission as a secondary endpoint. Finally, as compelling evidence showed that the Disease Acrivity Score using 28-joint counts (DAS28) might not provide a reliable definition of remission, or sometimes even low disease activity, the group suggested replacing DAS28 as a measurement instrument to evaluate disease activity in RA clinical trials. Proposed alternatives included SDAI, CDAI and Boolean criteria.

Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force

BACKGROUND

Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.

OBJECTIVE

To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.

METHODS

A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.

RESULTS

The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).

CONCLUSIONS

The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update

In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.