Abstract
We investigated the frequency of remission according to the disease activity score (DAS28) definition, modified American Rheumatology Association (ARA) criteria, and the frequency of an achievement of a functional status above defined thresholds ('functional remission', 'physical independence') in rheumatoid arthritis (RA) patients treated with either biologics or conventional DMARDs. We used the data of a prospective cohort study, the German biologics register RABBIT (German acronym for Rheumatoid Arthritis – Observation of Biologic Therapy) to investigate the outcomes in RA patients with two or more DMARD failures who received new treatment with biologics (BIOL; n = 818) or a conventional DMARD (n = 265). Logistic regression analysis was applied to adjust for differences in baseline risks. Taking risk indicators such as previous DMARD failures or baseline clinical status into account, we found that biologics doubled the chance of remission compared to conventional DMARD therapies (DAS28 remission, adjusted odds ratio (OR) 1.95 (95% confidenece interval (CI) 1.2–3.2)); ARA remission, OR 2.05 (95% CI 1.2–3.5)). High remission rates (DAS28 remission, 30.6%; ARA remission, 16.9%) were observed in BIOL patients with a moderate disease activity (DAS28, 3.2 to 5.1) at the start of treatment. These rates decreased to 8.5% in patients with DAS28 > 6. Sustained remission at 6 and 12 months was achieved in <10% of the patients. Severely disabled patients (≤50% of full function) receiving biologic therapies were significantly more likely to achieve a status indicating physical independence (≥67% of full function) than controls (OR 3.88 (95% CI 1.7–8.8)). 'Functional remission' (≥83% of full function) was more often achieved in BIOL than in controls (OR 2.18 (95% CI 1.04–4.6)). In conclusion, our study shows that biologics increase the chance to achieve clinical remission and a status of functional remission or at least physical independence. However, temporary or even sustained remission remain ambitious aims, which are achieved in a minority of patients only.
Highlights
Considering all available therapeutic options, today's treatment of rheumatoid arthritis (RA) differs substantially from what it was a decade ago
ARA = American Rheumatology Association; BIOL = patients treated with biologics; CI = confidence interval; CON = patients receiving conventional DMARD treatment; CRP = C-reactive protein; DAS28 = disease activity score based on 28 joint counts; DMARD = disease modifying anti-rheumatic drugs; HAQ = Health Assessment Questionnaire; ESR = erythrocyte sedimentation rate; FFbH = Funktionsfragebogen Hannover (Hannover Functional Status Questionnaire); MTX = methotrexate; Odds ratios (OR) = odds ratio; RA = rheumatoid arthritis; RABBIT = German biologics register (German acronym for Rheumatoid Arthritis – Observation of Biologic Therapy); SJC = 28-joint count of swollen joints; TJC = 28-joint count of tender joints; TNF = tumor necrosis factor
This study was conducted to investigate the remission rates according to two different criteria and the achievement of two endpoints for functional outcome in a cohort of patients treated with biologics in daily practice and to compare these results with a control group of patients who changed their conventional DMARD treatment because of inefficacy or intolerance
Summary
Considering all available therapeutic options, today's treatment of rheumatoid arthritis (RA) differs substantially from what it was a decade ago. Liximab, etanercept, adalimumab, and anakinra was demonstrated in randomized controlled trials in the majority of RA patients enrolled [1,2,3,4,5]; less is known regarding the effectiveness of these drugs in daily rheumatological care. Standard patients differ from those enrolled into randomized controlled trials [6] with regard to disease severity, treatment history, and comorbidity. Randomized clinical trials usually focus on demonstrating relative rather than absolute improvement. In the treatment of individual patients, it is crucial to reach absolute targets like remission, low inflammatory activity, no pain, or a high functional capacity [7]
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