Combination Of DMARDs Research Articles

Diagnosis and treatment of rheumatoid arthritis

Rheumatoid arthritis today is still not curable but satisfactory treatable. Treatment targets include clinical remission (or at least low disease activity), lack of radiological destructions and functional disability as well as acceptable life quality and unimpaired working ability. Diagnosing and adequately treating the disease as early as possible is essential for a favourable long-term outcome. Treatment to target with validation and if necessary modification at least every three months until target is achieved ensures good results. Predominantly treatment starts with a combination of methotrexate and glucocorticoids followed by a conventional DMARD combination and then addition of a biologic DMARD in case of failing target. Presence of adverse risk factors and/or high disease activity a cDMARD/bDMARD combination might be used already after starting treatment failure. Additional treatment options such as physiotherapy should be added. Altogether with current treatment possibilities burden of disease declined dramatically in recent years.

The good EULAR response at the first year is strongly predictive of clinical remission in rheumatoid arthritis: results from the TARAC cohort.

The purpose of this study was to identify the prevalence and prognostic factors of clinical remission in patients with rheumatoid arthritis (RA). The Thai Army Rheumatoid Arthritis Cohort (TARAC) patients were included if baseline data were available. Clinical remission was defined as 28-joint count disease activity scores (DAS28) <2.6 in the last two consecutive visits, at least 3months apart. Three hundred and thirty-five patients were enrolled, and 89.9% were female. Mean (SD) age was 61years (11.4), and mean disease duration was 145.9months (93.7). Rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) were positive in 69.9 and 67.8%, respectively. Eighty-nine percent of patients were treated with synthetic DMARDs, of which 29% received monotherapy. The combination of biologic and synthetic DMARDs was used in 10.4% of the patients. Clinical remission was observed in 49 patients (14.6%). Early diagnosis and treatment within 12months of onset (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.02-3.74, p = 0.04), rheumatoid factor negativity (OR 2.10, 95% CI 1.04-4.21, p = 0.04) and good EULAR response at the end of the first year of treatment (OR 2.75, 95% CI 1.08-6.99, p = 0.03) were associated with clinical remission in univariate analysis. In multivariate regression analysis, only a good EULAR response at the first year was significantly correlated with clinical remission in this study (OR 3.1, 95% CI 1.15-8.36, p = 0.03). Although remission is currently a treatment goal in patients with RA, only one-seventh of patients have achieved sustained clinical remission in clinical practice. The good EULAR response at the end of the first year was an independent predictive factor of clinical remission.

FRI0254 Predictive Value of Pretreatment Resistin Levels for Erosive Disease in Early RA Treated with DMARDS and Infliximab

BackgroundResistin is an adipocytokine related to insulin resistance, inflammation and arthritis (1).ObjectivesWe investigated if resistin is associated with the disease activity and inflammation in DMARD-naïve rheumatoid arthritis (RA) patients, if...

OP0036 Fewer Patients on Biologicals and Better Functional Ability Two Years after Induction Therapy with Combination DMARD Therapy versus Methotrexate Monotherapy

BackgroundFewer patients on biologicals and better functional ability two years after induction therapy with combination DMARD therapy versus methotrexate monotherapyObjectivesTo assess differences in frequency of biological therapy use in early...

FRI0302 Tocilizumab, DMARDS and Glucocorticoids in Rheumatoid Arthritis – Interim Analysis of the German Non-Interventional Study Ichiban

BackgroundThe ICHIBAN study collects routine clinical data to evaluate the effectiveness and safety of tocilizumab (TCZ) in patients with rheumatoid arthritis (RA) in real world practice over a period of...

THU0415 Changing Patterns in Prescribing in Rheumatoid Arthritis

BackgroundPrescribing patterns in Rheumatoid Arthritis have evolved over recent decades. There is now clear evidence that combination DMARDs and biologics can acheive better disease control. This is guided by the...

OP0123 Can We Use Ultrasound to Identify Rheumatoid Arthritis Patients in Remission Who Can Taper Their Medication?

BackgroundTapering of medication in rheumatoid arthritis (RA) patients is becoming increasingly important due to the effectiveness of both biological therapy and tight-controlled treatment. Patients are able to reach the state...

AB1190-HPR Patients' Experiences with Intensive Combination Treatment Strategies for Early Rheumatoid Arthritis: A Longitudinal Qualitative Study Embedded in the Carera Trial

BackgroundThe current recommendations for early Rheumatoid Arthritis (eRA) management focus on achieving clinical remission as soon as possible with an early and intensive treatment. Understanding patients' experiences and ideas regarding...

SAT0224 Macrophage Targeting by Positron Emission Tomography (PET) Imaging Detects Subclinical Synovitis in Hands and Wrists in Early RA Patients in Clinical Remission

BackgroundIn rheumatoid arthritis (RA), intensive treatment regimens aim to achieve a status of clinical remission (CR). Unfortunately, recurrent flares in RA patients in CR are not an uncommon phenomenon1. Studies...

FRI0020 Presence of Synovial Lymphocyte Aggregates Predicts Clinical Response to DMARD Therapy in Patients with Early Rheumatoid Arthritis

BackgroundPredicting prognosis in patients with early RA remains a challenge. There is currently limited data from early arthritis cohorts examining the relationship between synovial pathotype, clinical phenotype and clinical outcome,...

THU0137 Associated with A Glucocorticoid Bridging Scheme, Methotrexate is as Effective Alone as in Combination with Other DMARDS for Early Rheumatoid Arthritis, with Fewer Reported Side Effects: 16 Weeks Remission Induction Data from the Carera Trial

BackgroundIn line with the window of opportunity theory, intensive DMARD combination therapy with glucocorticoids (GCs) is probably the most effective treatment approach for early Rheumatoid Arthritis (eRA), but the ideal...

OP0127 Impact of Disease Activity and Treatment on Progression of Functional Limitation in RA

BackgroundFunctional limitation is a key outcome in rheumatoid arthritis and a key driver of the cost of RA in health economic models. Due to restrictive inclusion/exclusion criteria and short follow...

THU0240 Long-Term Disease Course in an Inception Cohort of Patients with Early RA – Persistently Active Disease is Common, Particularly in Women

BackgroundThe true impact of biologic agents in rheumatoid arthritis (RA) is difficult to assess without knowledge on the long-term disease course and outcome in the time preceding the introduction of...

Cost-effectiveness of treatment strategies using combination disease-modifying anti-rheumatic drugs and glucocorticoids in early rheumatoid arthritis.

The aim of this study was to estimate the cost-effectiveness of combination DMARDs with short-term glucocorticoids in early active RA using data from the 2-year Combination of Anti-Rheumatic Drugs in Early RA (CARDERA) trial. CARDERA enrolled 467 patients with active RA of <24-months duration. All patients received MTX; half received step-down prednisolone and half ciclosporin in a placebo-controlled factorial design. Differences in mean costs and quality-adjusted life-years (QALYs) over 24-months follow-up were estimated using patient-level data from a UK health service perspective and 2011-12 costs. Two-year costs for each treatment strategy showed primary care costs were negligible across all groups. Drug costs were lowest with MTX/ciclosporin and triple therapy. Hospital costs were lowest with MTX/prednisolone and triple therapy. Triple therapy was least costly and most effective; it dominated all other strategies. At positive values for a QALY in the typical UK range (£20 000-30 000) the probability that triple therapy was the most cost-effective strategy was 0.9. Results were robust to methods used to impute missing data. Intensive treatment of early RA with triple therapy (two DMARDs and short-term glucocorticoids) is both clinically effective and cost effective.

97. Final 5-Year Safety and Efficacy Results of a Phase 3, Randomized, Placebo-Controlled Trial of Golimumab in Methotrexate-NaïVe Patients with Rheumatoid Arthritis

randomized controlled trial (RCT)—the Combination Anti-Rheumatic Drugs in Early RA (CARDERA) trial—to examine whether responses to intensive combination treatments in early RA differ by ACPA status. Methods: The CARDERA trial randomized 467 patients with early active RA to receive: (i) MTX (ii) MTX/ciclosporin (iii) MTX/prednisolone or (4) MTX/ciclosporin/prednisolone in a factorial-design. Patients were assessed 6 monthly for 2 years. In this analysis we evaluated 431 patients with archived serum available for ACPA status determination (using the anti-CCP2 ELISA assay). To minimize multiple testing we used a mixed-effects repeated measures ANOVA model to test for an interaction between ACPA and treatment on mean changes from baseline for each outcome (Larsen, DAS28, HAQ, EuroQol, PCS and MCS scores). When a significant interaction was present, mean changes in outcomes were compared by treatment group at each time point stratified by ACPA status using t-tests. Odds ratios (ORs) for the onset of new erosions with treatment were calculated stratified by ACPA. Results: Of the 431 RA cases, 310 (72%) were ACPA-positive; 121 (28%) were ACPA-negative. ACPA status influenced the effect of treatment on radiological progression, with a significant ACPA*treatment interactive effect on Larsen score changes seen in the ANOVA model (P< 0.001). ACPA-positive patients had significant reductions in Larsen score progression with all treatments; no effect was seen in ACPAnegative RA. ACPA-positive patients receiving triple therapy had the greatest benefits: mean Larsen score increases over 2 years were 3.66 (95% CI 2.27, 5.05) with triple therapy and 9.58 (95% CI 6.76, 12.39) with monotherapy; OR for new erosions with triple therapy vs monotherapy was 0.32 (95% CI 0.14, 0.72; P1⁄40.003). ACPA-negative patients had minimal radiological progression irrespective of treatment strategy: mean Larsen score increases over 2 years comprised 1.70 (95% CI 0.29, 3.10) with triple therapy and 2.72 (95% CI 1.15, 4.29) with monotherapy; only 7% developed new erosions. The beneficial effects of high-dose corticosteroids on reducing disease activity and improving physical health were confined to ACPA-positive RA. Conclusion: ACPA status influences the need for, and response to, combination DMARDs and high-dose tapering corticosteroids in early RA. Combination DMARDs and corticosteroids only provided radiological, disease activity and physical health benefits in ACPA-positive patients. This suggests that current UK guidelines advocating combination DMARDs and corticosteroids in all early active RA patients require reconsideration. Funding: This research was supported Arthritis Research UK [Grant Number 19739 to ICS], the National Institute for Health Research (NIHR) and the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London. Disclosure statement: The authors have declared no conflicts of interest.

96. ACPA-Positive and ACPA-Negative Rheumatoid Arthritis Differ in their Requirements for Combination Dmards and Corticosteroids

96. ACPA-Positive and ACPA-Negative Rheumatoid Arthritis Differ in their Requirements for Combination Dmards and Corticosteroids

The performance of matrices in daily clinical practice to predict rapid radiologic progression in patients with early RA

ObjectiveTo compare in daily clinical practice the reliability of matrices that forecast rapid radiologic progression (RRP) at year one, at year two, and over 2 years in patients with early rheumatoid arthritis (RA). MethodsOverall, 74 early RA patients with X-rays of hands and feet at baseline, year one, and year two were included. Initial DMARD combination therapy with steroids (ICTS) or DMARD monotherapy (IMT) was initiated according to patients' RA severity, based on rheumatologist opinion. The images were scored via the modified Sharp/van der Heijde (SvH) method. A total Sharp score progression of equal or higher than five per year was considered RRP.Six matrices were tested: ASPIRE CRP/ESR matrices, the BEST matrix, two SWEFOT matrices, and the ESPOIR matrix. Patients were placed in each of them yielding a RRP probability. The performance was tested by Area Under the Curve analysis reflecting the predictive value. ResultsFour patients developed RRP in year one, five in year two, and four over 2 years. With regard to face validity, the predicted probability did not correspond to the risk in reality: the one ICTS patient who developed RRP over 2 years was always found in the lowest RRP categories of all matrices. The ASPIRE CRP matrix yielded at least a moderate predicting value for the three time points. The other matrices showed moderate to no predicting value. ConclusionThe performance of all matrices was disappointing and it is impossible to fully rely on the existing matrices in daily clinical practice.

Evaluation of dyslipidaemia in patients with rheumatoid arthritis in South Indian population

BackgroundRheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality which is mainly due to accelerated atherosclerosis. The inflammation in rheumatoid arthritis is likely to alter the lipid profile in these patients resulting in dyslipidaemia which is an important cardiovascular disease (CVD) risk factor. Material and methods46 patients diagnosed with RA as per 1987 revised American Rheumatology Association criteria were included in the study. Of the 46 patients, 24 were newly diagnosed RA patients and 22 patients were undergoing treatment with a combination of DMARDs with (n = 14) or without (n = 8) corticosteroids. 46 age and sex matched healthy subjects were included as controls. Total cholesterol (TC), triglycerides, HDL cholesterol, lDL cholesterol, apolipoprotein A-1 (apo A-1), apolipoprotein B (apo B) and lipoprotein(a) (Lp(a)) were measured. ResultsTC, HDL cholesterol and LDL cholesterol levels were similar in all the three study groups. Both groups of patients had significantly elevated triglyceride, apo B and Lp(a) levels compared to controls (p < 0.05). RA patients undergoing treatment had significantly elevated apo A-1 levels when compared to controls (p < 0.05). ConclusionsThe dyslipidaemia pattern in RA patients in the present study is evident in the form of elevated triglycerides, apo B and Lp(a) levels. The beneficial effects of a higher atheroprotective apo A-1 in patients undergoing treatment may be counteracted by the presence of high triglycerides, apo B and Lp(a).

Role for infliximab uncertain as targeted DMARD combinations achieve effective disease control

Rheumatoid arthritis: Role for infliximab uncertain as targeted DMARD combinations achieve effective disease control

Not Better but Quite Good

Not Better but Quite Good