Early Rheumatoid Arthritis Population Research Articles

Can baseline ultrasound results help to predict failure to achieve DAS28 remission after 1 year of tight control treatment in early RA patients?

BackgroundAt present, there are no prognostic parameters unequivocally predicting treatment failure in early rheumatoid arthritis (RA) patients. We investigated whether baseline ultrasonography (US) findings of joints, when added to baseline clinical, laboratory, and radiographical data, could improve prediction of failure to achieve Disease Activity Score assessing 28 joints (DAS28) remission (<2.6) at 1 year in newly diagnosed RA patients.MethodsA multicentre cohort of newly diagnosed RA patients was followed prospectively for 1 year. US of the hands, wrists, and feet was performed at baseline. Clinical, laboratory, and radiographical parameters were recorded. Primary analysis was the prediction by logistic regression of the absence of DAS28 remission 12 months after diagnosis and start of therapy.ResultsOf 194 patients included, 174 were used for the analysis, with complete data available for 159. In a multivariate model with baseline DAS28 (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.2–2.2), the presence of rheumatoid factor (OR 2.3, 95% CI 1.1–5.1), and type of monitoring strategy (OR 0.2, 95% CI 0.05–0.85), the addition of baseline US results for joints (OR 0.96, 95% CI 0.89–1.04) did not significantly improve the prediction of failure to achieve DAS28 remission (likelihood ratio test, 1.04; p = 0.31).ConclusionIn an early RA population, adding baseline ultrasonography of the hands, wrists, and feet to commonly available baseline characteristics did not improve prediction of failure to achieve DAS28 remission at 12 months.Trial registrationClinicaltrials.gov, NCT01752309. Registered on 19 December 2012.

The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis.

Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. This study is registered as PROSPERO CRD42015017336. The National Institute for Health Research Health Technology Assessment programme.

Validation of Self-Reported Cardiovascular Disease and Associated Co- Morbidities in a Large Canadian Cohort of Early Inflammatory Arthritis

Objective: Cardiovascular disease (CVD) and risk factors for CVD (smoking, hypertension, dyslipidemia and diabetes) are commonly associated with Rheumatoid Arthritis (RA). We aimed to determine the validity of selfreported CVD events and risk factors in the Canadian Early Arthritis Cohort (CATCH). Methods: CATCH is a multicenter inception cohort of patients with early RA. Various co-morbidities and pharmacologic therapies are self-reported at baseline and at each follow-up visit. Using a randomly selected subgroup of subjects enrolled in CATCH from one representative site, we performed a detailed review of their complete medical record to identify diagnoses of CVD events, risk factors and drug therapies. The validity of selfreported variables was determined using the Cohen’s kappa statistic. Results: The validation subgroup (N=141) was similar to the entire CATCH population (N=2626) with respect to baseline demographics and RA disease characteristics. There was very good agreement between self-report and the medical record for cardiovascular or cerebrovascular events (kappa=0.66), as well as for hypertension and diabetes (kappa=0.70 and 0.81, respectively). Subjects tended to under-report dyslipidemia and the reporting of lipid-lowering and antiplatelet/anticoagulant agents was inaccurate compared to the medical record. Conclusion: Self-reported cardiovascular disease, hypertension and diabetes was representative of the medical record suggesting that these self-reported variables are valuable for future studies of this early RA population.

164. A Comparison of the Indicators of Hand Function in early RA Populations from the UK and China

Background: Rheumatoid arthritis (RA) is a universal disease with clinical presentations and impacts varying in different ethnic groups. The process of inflammatory joint damage quantified by ESR, CRP, number of tender and swollen joints can lead to structural impairment and deformity of wrists and hands. However, the relationship between hand impairment and disability in early RA is controversial. A comparison of this relationship in different population groups would add to the understanding of country-specific impacts of RA. This study compared the correlations of disease activity and hand impairment with self-report hand function between two early RA populations from the UK and China. Methods: A cohort comparison study was conducted. 60 Chinese patients recruited from Shanghai, China were matched on gender and age with 60 patients from a prospective early RA cohort from the UK (SARAH trial). The procedures of data collection in China followed the standard operating procedures employed in the SARAH trial. Outcome measures including MHQ, medical history and physical assessments were used to assess disease activity, hand impairment and function. Results: There was no significant association (P?0.05) between hand function with MCP joint deformity in either population group. Correlations between hand function with range of movement measured by active wrist flexion, combined finger flexion and composite finger extension were weak in both the UK and Chinese population (r?0.04, p?0.05). The associations between self-report overall hand function and full grip strength were moderate to weak in Chinese patients (dominant r=0.473 and non-dominant r=0.347, p?0.05). The correlations were weak between overall hand function and pinch grip among Chinese patients (p?0.05). However, correlations between hand function and full grip strength were moderate in UK patients (dominant r=0.582 and non-dominant r=0.555, p?0.05). Moderate relationships were found between hand function and pinch strength in the UK patients (dominant r=0.647 and non-dominant r=0.624, p?0.05). There were strong to moderate negative correlations between hand function and pain in both population groups (UK r=-0.690 and China r=-0.458, p?0.05). A moderate negative correlation was found between hand function and swelling (r=-0.45, p?0.001) and a moderate correlation between dexterity and hand function (dominant r=0.441, non-dominant r=0.440, p?0.05) in Chinese patients. However, no significant association (P?0.05) was found between hand function and swelling or hand function and dexterity among UK patients. Conclusion: In early RA populations in both the UK and China, hand strength, range of movement and pain are indicators of hand function. There is a weaker correlation between hand strength with self-reported hand function in the Chinese population compared with the UK RA patients. Swelling is not an indicator of hand function in the UK population. Test Overall hand function (dominant hand) China (dominant hand) UK (dominant hand) China (non-dominant hand) UK (non-dominant hand) Correlation P-value Correlation P-value Correlation P-value Correlation P-value Spearman’s rho MCP joint Deformity -0.321 0.221 0.121 0.359 -0.210 0.107 0.055 0.067 Pearson r Active wrist extension 0.025 0.850 0.023 0.864 -0.025 0.850 0.864 0.023 Pearson r Active wrist flexion 0.290 0.025 0.276 0.033 0.328 0.010 0.338 0.008 Spearman’s rho Combined finger flexion -0.381 0.003 -0.350 0.007 -0.357 0.005 -0.361 0.005 Pearson r Composite finger extension 0.379 0.003 0.394 0.002 0.405 0.001 0.189 0.152 Spearman’s rho Dexterity 0.441 0.000 -0.123 0.354 0.440 0.000 0.086 0.515 Spearman’s rho Full grip strength 0.473 0.000 0.582 0.000 0.347 0.007 0.647 0.000 Spearman’s rho Pinch grip strength 0.371 0.004 0.647 0.000 0.295 0.022 0.555 0.000 Test Overall hand function (both hands) China UK Correlation P-value Correlation P-value Pearson r Pain (both hands) -0.458 0.000 -0.690 0.000 Spearman’s rho Swelling (both hands) -0.450 0.000 -0.093 0.479 a statistically significant (p?0.05)

Update on the use of abatacept for the treatment of rheumatoid arthritis

Abatacept is approved for the treatment of moderate-to-severe active rheumatoid arthritis (RA) patients with inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs), including methotrexate or a TNF antagonist, and can be used either as monotherapy or concomitantly with nonbiologic DMARDs. It can be administered either intravenously or subcutaneously. It has demonstrated to improve signs and symptoms of RA, physical function and health-related quality of life, and it inhibits radiographic progression of structural damage across a wide range of early and long-standing RA populations. The safety profile appears good and close to RA patients treated with nonbiologic DMARDs. Meta-analysis and real-world studies support these findings. This article reviews published data on clinical and radiographic efficacy as well as the safety of this drug, incorporating recent relevant information reported at scientific meetings.

THU0506 In an Inception Cohort of 175 DMARD NaÏve Ra Patients Classified According to the 2010 ACR/EULAR Criteria a Large Proportion of Patients does not Fulfill the 1987 ACR Criteria

BackgroundThe new 2010 ACR/EULAR classification criteria for rheumatoid arthritis (RA) have shown good diagnostic properties in early arthritis cohorts, but it is not well known how the population of early...

Effect of baseline rheumatoid factor and anticitrullinated peptide antibody serotype on rituximab clinical response: a meta-analysis

BackgroundStudies examining the relationship between serological status (rheumatoid factor and/or anticitrullinated antibody) and rituximab treatment outcome in rheumatoid arthritis (RA) have been hampered by limited numbers of seronegative patients.ObjectiveTo carry...

Responsiveness of self‐report and therapist‐rated upper extremity structural impairment and functional outcome measures in early rheumatoid arthritis

To provide a responsiveness analysis of the self-report and therapist-rated upper extremity functional outcome measures used in a rehabilitation trial. A variety of commonly used therapist-assessed and self-report structural impairment and functional outcome measures were compared for the ability to detect and measure change in wrist and hand status in an early rheumatoid arthritis population over 12 months. Responsiveness was measured using the standardized response mean (SRM) and effect size (ES). The most responsive measures were the Michigan Hand Outcomes Questionnaire (SRM 0.49 [95% confidence interval (95% CI) 0.27, 0.72], ES = 0.37 [95% CI 0.21, 0.54]), dominant metacarpophalangeal joint ulnar deviation (SRM 0.46 [95% CI 0.27, 0.65], ES = 0.58 [95% CI 0.34, 0.82]), and mean power handgrip test (SRM 0.45 [95% CI 0.26, 0.64], ES = 0.32 [95% CI 0.18, 0.45]) The least responsive measure was the Health Assessment Questionnaire (SRM -0.12 [95% CI -0.31, 0.08], ES = -0.08 [95% CI -0.21, 0.05]). Over 12 months, there was substantial variation in wrist and hand outcome measures to detect change over time in an early RA population. Careful consideration is required to choose the most appropriate measure that can detect change.

Self-Reported Hand Functional Ability measured by the DASH in Individuals with Early Rheumatoid Arthritis

Self-report accounts of functional ability are important for clinicians to gain insight into individuals’ perspectives of the personal impact of injury or disease. This short report describes a study of self-report upper limb ability using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire in a sample of people with early rheumatoid arthritis. The DASH is a reliable and valid tool for use within rheumatology. The most difficult upper limb tasks to complete were reported to be activities that required sustained force and power, followed by tasks that required fine finger movements and prehension tasks. The DASH questionnaire proved to be an outcome measure that discriminated well between different levels of reported functional upper limb ability; it was reported to be easy to complete by patients, and was straightforward and quick to score. The compact summary score makes it a useful clinical and research tool and one that can be recommended in an early rheumatoid arthritis population.

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population.

To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation). Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments. Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist. Strong correlations (> 0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side. In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.

PAM18: PERFORMANCE ASSESSMENT OF TWO FATIGUE INSTRUMENTS IN AN EARLY RHEUMATOID ARTHRITIS COHORT

OBJECTIVE: The importance of assessing fatigue in rheumatoid arthritis (RA) has been confirmed in numerous studies. Several instruments are available to assess fatigue, however, the psychometric properties of most have been determined in various populations other than RA and the instruments tend to measure different aspects of fatigue. The objective of this study was to assess the performance of two fatigue instruments, one was developed in the RA population and the other in a nondisease-specific population. METHODS: This study is an ongoing prospective, multi-center, observational study conducted to document long-term functional, clinical, humanistic and economic outcomes, and treatment patterns in patients with new onset rheumatoid arthritis. Two fatigue instruments were used to assess RA patients: The Functional Assessment of Chronic Illness Therapy-Fatigue Subscale (FACIT-F), an instrument used primarily in oncology populations, and the Multidimensional Assessment of Fatigue (MAF), developed in an RA population. MAF measures four dimensions of fatigue (severity, distress, degree of interference in daily activities, and timing). At baseline, patients were requested to complete both the 16-item, MAF and the 13-item, FACT-F via telephone interview. Using baseline data only, the correlation between the MAF and the FACIT-F was tested in 133 patients with early RA (signs and symptoms> 3 months and <12 months). RESULTS: Patients mean + SD age was 55 + 15 years and 77% were female. Mean + SD MAF score was 23.3 + 12.3 with a normal range of 1(no fatigue)–50(fatigue). Mean FACIT-F score was 33.2 + 9.3 with a normal range of 52 (no fatigue)–0 (fatigue). The aggregate scores for each instrument were highly correlated with a Pearson's coefficient of −0.81 (p < 0.001). CONCLUSION: Based on this analysis, it appears that the FACIT-F has validity for use in the early RA population. However, as follow-up assessments are completed, a more detailed analysis may reveal additional psychometric properties of the instrument in the early RA population and with disease progression.