POS0303 TREATMENT DECISIONS IN AXIAL SPONDYLOARTHRITIS ARE MORE THAN TREAT TO TARGET

Abstract

BackgroundSeveral guidelines advise treating axial spondyloarthritis (axSpA) patients according to the ‘treat-to-target principles’ (T2T)1 although a clear target has not yet been defined. Disease activity measures, which are often used as targets, do not always reflect pure inflammatory disease activity. Currently is it not known if T2T is applied in axSpA clinical practice and what factors influence treatment decisions.ObjectivesTo assess residual disease activity according to the physician’s opinion, patient’s opinion and disease activity measures and the subsequent treatment decisions made in axSpA patients.MethodsThis cross-sectional multicentre study included 249 patients with a clinical diagnosis of axSpA ≥ 6 months. Remission and low disease activity according to Bath Ankylosing Spondylitis Disease Activity Index (BASDAI <1.9 and <3.5 respectively), physician’s, and patient’s opinion was assessed. Questionnaires including patient reported outcomes (PROs) such as the Patient Global Assessment (PGA) of disease activity, Bath Ankylosing Spondylitis Functional Index (BASFI), ASAS-Health Index (ASAS-HI), central sensitization inventory (CSI), Brief Illness Perception Questionnaire (B-IPQ), and satisfaction with treatment; or questions regarding motivations for treatment decisions were filled in by patients and physicians respectively.ResultsIn this cohort, 115/249 patients were in remission according to the physician. Of these 115 patients, 67% (n=80) indeed perceived their disease as being inactive, but only 37% (n=43) reached remission according to the BASDAI. This shows a significant level of discrepancy in comparison with the physician’s opinion. Of note, 30% (n=35) even reported a BASDAI >3.5. In 93% (n=107) treatment-intensity remained unchanged and in 6% (n=5) treatment was tapered. Physicians motivated that treatment was left unchanged in the majority of these patients because of remission (n=55, 48%), low disease activity (n=28, 24%), or complaints not related to axSpA (n=13, 12%). The latter two motives were most frequently mentioned for the patients with a BASDAI >3.5 (respectively n=13, 39% and n=9, 27%). Residual disease activity was present in 134/249 patients according to the physician’s opinion and 67% (n=90) of these patients also perceived their disease as active. In 89% (n=119) BASDAI score was >1.9 and in 62% (n=83) >3.5. In 61% (n=51) of these patients with residual disease and a BASDAI >3.5, treatment remained unchanged, as well as in 84% (n=43) of the patients with a BASDAI between 1.9 and 3.5. Physician’s most frequently mentioned motives for not changing treatment in the residual disease activity group were: low disease activity achieved (n=29, 25%), the need to await the effect of the current treatment (n= 23, 20%), or complaints that were not related to axSpA (n=9, 8%). The second (n=20, 39%) motive was most frequently mentioned for unchanged treatment in the BASAI >3.5 group and additionally, physicians mentioned that these patients had a preference to continue their current treatment despite high disease activity (n=5, 10%).Analyses of PROs showed significantly higher scores for PGA of disease activity, several subdomains of the B-IPQ, general fatigue and morning stiffness in patients with remission according to the physician despite a BASDAI >3.5 compared to patients with residual disease according to the physician with a BASDAI <1.9.ConclusionThis study shows that physicians in daily clinical practice do not always adjust treatment according to the T2T-principles in patients with residual disease activity when measured by BASDAI scores, either because low disease activity is achieved, because they classify the patient as being in remission, as having low disease activity, or because there was a need to await the efficacy of the current treatment. Further studies are needed to investigate if treatment choices made in clinical practice result in under-treatment of axSpA patients with worse outcome in comparison to the T2T approach.