Rheumatoid Arthritis In Clinical Remission Research Articles

Long-term efficacy of a 2-year MRI treat-to-target strategy on disease activity and radiographic progression in patients with rheumatoid arthritis in clinical remission: 5-year follow-up of the IMAGINE-RA randomised trial

ObjectiveTo investigate whether a 2-year MRI treat-to-target strategy targeting the absence of osteitis combined with clinical remission, compared with a conventional treat-to-target strategy targeting clinical remission only (IMAGINE-rheumatoid arthritis (RA)...

Characteristics and prevalence of clinical remission of rheumatoid arthritis in a nationwide study from Indonesia

AbstractAimTo investigate the clinical characteristics, DMARD treatment pattern, remission rate, and factors associated with disease remission of rheumatoid arthritis (RA) patients in Indonesia.MethodA multicenter survey was conducted in 2019–2020 involving 16 hospitals in Indonesia. Inclusion criteria were RA patients who fulfilled the 2010 ACR/EULAR classification criteria, were aged ≥18 years, and have been treated with 1 DMARD or more for at least 6 months, with exclusion criteria being the co‐existence of other autoimmune diseases or pain syndromes. Disease activities and remission rate were defined using DAS28‐ESR.ResultsA total of 870 patients were completed for analysis. Remission was achieved in 24.5% of patients, while low disease activity in 18.5%, moderate disease activity in 44.6%, and high disease activity in 12.4%. The distribution of conventional DMARDs from subjects was methotrexate 69.9%, leflunomide 15.9%, sulfasalazine 12.0%, chloroquine/hydroxychloroquine 8.9%, and cyclosporine 4.8%. Patients treated with biologic DMARDs were only 0.3%. The mean methotrexate dose was 11.2 ± 4.0 mg/week, and the mean methotrexate duration was 45.1 ± 36.6 months. The majority of patients received glucocorticoids (65.5%). 71.1% received DMARD monotherapy, while 28.9% had combined DMARDs. According to the multivariate analysis, delayed time to diagnosis and treatment (>6 months), DMARD monotherapy, and glucocorticoid use were negatively associated with disease remission.ConclusionThe remission rate of Indonesian RA patients is 24.5%, and low disease activity is 18.5%. Methotrexate and leflunomide are the most frequent conventional DMARDs used. Delayed diagnosis, delayed treatment, and DMARD monotherapy contributed to the current low remission rate in Indonesia.

Comment on: Impact of interstitial lung disease on clinical remission of rheumatoid arthritis: results from the IORRA cohort: Reply.

Comment on: Impact of interstitial lung disease on clinical remission of rheumatoid arthritis: results from the IORRA cohort: Reply.

Comment on: Impact of interstitial lung disease on clinical remission of rheumatoid arthritis: results from the IORRA cohort.

Comment on: Impact of interstitial lung disease on clinical remission of rheumatoid arthritis: results from the IORRA cohort.

Association between patient-reported outcomes and impairments in work and activity in patients with rheumatoid arthritis in clinical remission: A retrospective analysis using the IORRA database.

To explore the patient-reported outcomes (PROs) associated with work productivity and activity impairment (WPAI) in patients with rheumatoid arthritis (RA) in clinical remission. We enrolled patients with RA ≥18 years and with a simplified disease activity index ≤3.3 from the Institute of Rheumatology, Rheumatoid Arthritis data set collected in October 2017. The pain-visual analogue scale, patients' global assessment visual analogue scale (VAS), Japanese version of the Healthcare Assessment Questionnaire (J-HAQ) Disability Index, and duration of morning joint stiffness were selected as the PROs. To evaluate work productivity and activity, the WPAI for RA instrument (WPAI-RA) was used. To assess the contribution of each PRO to the WPAI-RA score, an analysis of variance model was constructed. The mean age of the 2614 patients was 62.4 years; 85.1% were female. Median values of the WPAI-RA score were 1.1% for absenteeism, 6.5% for presenteeism, 7.4% for work impairment, and 10.2% for activity impairment. Morning joint stiffness contributed the most to absenteeism (18.0%), while pain-VAS contributed the most to presenteeism (57.4%), work productivity loss (51.1%), and daily activity impairment (53.7%). J-HAQ was the second most contributing factor to presenteeism (17.4%), work productivity loss (16.3%), and daily activity impairment (26.0%). The pain-VAS and J-HAQ highly contributed to WPAI in patients with RA in clinical remission.

Assessment of inflammation in patients with rheumatoid arthritis using thermography and machine learning: a fast and automated technique

ObjectivesSensitive detection of joint inflammation in rheumatoid arthritis (RA) is crucial to the success of the treat-to-target strategy. In this study, we characterise a novel machine learning-based computational method to...

Role of booster with BNT162b2 mRNA in SARS-CoV-2 vaccination in patients with rheumatoid arthritis.

Only case reports and small clinical series report the effects of booster vaccination with BNT162b2 in patients with rheumatoid arthritis (RA). We studied 200 patients with RA in clinical remission evaluated with the DAS28. All patients were vaccinated for SARS CoV-2 with the BNT162b2 mRNA vaccine. The value of anti-SARS-CoV 2 Spike RBD IgG antibodies was determined at T1 (3 weeks after first vaccination) and T2 (3 weeks after booster). In addition, patients underwent assessment of lymphocyte subpopulations by flow cytometry analysis before starting the vaccination cycle (T0). Furthermore, the serum antibody levels of 96 health care workers (HCWs) were analyzed for comparison. DAS28 values at T0, T1, and T2 indicated remission or low disease activity in all patients. Levels of anti-SARS CoV-2 IgG at T1 were higher in HCWs than in patients’ groups: 1562.00 BAU WHO/mL [975.00–1632.00] vs 416.00 BAU WHO/mL [110.00, 1581.00], p <0.001. Anti-SARS COV2 IgG levels at T1 and at T2 were slightly lower in patients taking b/tsDMARDs than in patients under csDMARDs. Regression analysis evidenced age, treatment with abatacept (ABA), JAK inhibitors, and rituximab (RTX) as negative predictors of higher anti-SARS CoV-2 IgG levels at T1. Moreover, treatment with anti-IL6, anti-JAK, and anti-tumor necrosis factor (TNF) emerged as positive predictors of higher levels of anti-SARS CoV-2 IgG at T2. Our data show that despite the booster vaccine with BNT162b2, seroconversion in patients with rheumatoid arthritis is influenced by the background therapy, particularly for patients being treated with ABA and RTX.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12026-022-09283-y.

Superb microvascular imaging is as sensitive as contrast-enhanced ultrasound for detecting synovial vascularity in rheumatoid arthritis.

Detection of synovitis is essential for assessing rheumatoid arthritis (RA) activity and predicting prognosis. This study aimed to compare the diagnostic performance of superb microvascular imaging (SMI) with that of contrast-enhanced ultrasound (CEUS) in patients with RA in clinical remission. SMI and CEUS were applied to 63 patients with active RA and 48 patients with RA in clinical remission. Differences in positive synovial vascularity (SV) and its semi-quantitative scale were observed, and the correlations of SMI and CEUS results with C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF) were analyzed. For the 63 joints with active RA, the detection rates of SV as determined by SMI and CEUS were 90.5% (95% CI: 83.0-97.9%) and 93.7% (95% CI: 87.5-99.8%), respectively, with no significant difference observed between the two modalities (t=-1.137; P=0.260). There was good agreement between the two modalities in detecting positive blood flow (Kappa =0.784) and blood flow signal score (Kappa =0.792). For the 48 joints with clinical remission, the detection rates of SV determined by SMI and CEUS were 79.2% (95% CI: 67.2-91.1%) and 83.3% (95% CI: 72.4-94.3%), respectively, with no significant difference found between the two modalities (t=1.000; P=0.322). There was high consistency between the two modalities in detecting positive blood flow (Kappa =0.727) and blood flow signal score (Kappa =0.661). The vascularity scores of SMI and CEUS were positively correlated with CRP, ESR, and RF in the joints with active RA, but not in those with clinical remission. SMI is as sensitive as CEUS for detecting vessels in the synovium and displaying local SV in patients with RA who achieve clinical remission.

P215 In a treatment-naïve, early rheumatoid arthritis cohort, baseline ultrasound power Doppler synovitis and tenosynovitis are highly associated with remission when treated with first line etanercept + methotrexate (MTX) but not MTX alone

Abstract Background/Aims Clinical remission is the treatment target in rheumatoid arthritis (RA). In a treatment-naïve, early RA trial (VEDERA: ‘Very early Etanercept and Methotrexate versus Methotrexate with/without Delayed Etanercept in RA’), we previously reported the presence of ultrasound power Doppler synovitis (PDUS) at diagnosis that improved in the majority with treatment. For this study, we aimed to investigate specifically for an association of baseline PDUS and PD tenosynovitis (PDTS) with subsequent clinical remission (DAS28ESR ≤ 2.6) in VEDERA, also comparing the two treatment groups. Methods The ‘VEDERA’ trial randomised 120 treatment-naïve, new-onset RA patients to either first-line etanercept+methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT) regime with escalation to ETN+MTX if not in DAS28ESR remission at week 24. Clinically symptomatic and dominant hand (MCP 1-5, wrist, flexor tendons 1-5 and extensor carpii ulnaris tendon) ultrasound assessments were completed at baseline, weeks 12, 24 and 48. PDUS and PDTS were assessed semi-quantitatively and converted to dichotomous (absent = total score 0, present = total score ≥ 1) for this logistic regression analysis. Results At baseline, 68% (81/120) demonstrated PDUS and 68% also demonstrated PDTS overall. In the MTX-TT group, 63% (38/60) had PDUS and 62% (37/60) had PDTS at baseline. In ETN+MTX group, 72% (43/60) had PDUS and 75% (45/60) had PDTS at baseline. As per randomised trial, there were no differences in baseline demographics, DAS28ESR and HAQ between the groups. Overall, baseline PDUS was associated with week 24 remission and baseline PDTS was associated with week 24 and 48 remission (table 1). Baseline PDUS was particularly associated with week 24 remission in the ETN+MTX group, with a high OR (95% CI) of 6.83(1.2 - 38.91) compared to the MTX-TT group [1.75(0.5 - 6.14)]. Baseline PDTS was also associated with a high OR for week 48 remission in the ETN+MTX group (OR [95% CI] 9.13[1.77 - 47.02]) in contrast to an absence of association in the MTX-TT group. Conclusion Baseline PDUS and PDTS are associated with remission in early RA patients treated with TNF-inhibitor treatment. These measures may be useful to stratify patients early for TNF bDMARD to attain the target of clinical remission in RA. Disclosure R. Shukla: None. R. Hum: Other; R.H holds an Academic Clinical Fellowship funded by the National Institute for Health Research (NIHR) through the Integrated Academic Training (IAT) Programme. P. Ho: None. R.J. Wakefield: None. P. Emery: None. M.H. Buch: None.

Prediction of flare following remission and treatment withdrawal in early rheumatoid arthritis: post hoc analysis of a phase IIIb trial with abatacept

BackgroundDrug-free remission is a desirable goal in rheumatoid arthritis (RA) for both patients and clinicians. The aim of this post hoc analysis was to investigate whether clinical and magnetic resonance imaging (MRI) variables in patients with early RA who achieved remission with methotrexate and/or abatacept at 12 months could predict disease flare following treatment withdrawal.MethodsIn the AVERT study of abatacept in early RA, patients with low disease activity at month 12 entered a 12-month period with all treatment discontinued (withdrawal, WD). This post hoc analysis assessed predictors of disease flare at WD+6months (mo) and WD+12mo of patients with Disease Activity Score in 28 joints (DAS28)-defined remission (DAS28[C-reactive protein (CRP)] <2.6) at withdrawal using univariate and multivariable regression models. Predictors investigated included the Health Assessment Questionnaire–Disability Index (HAQ-DI), pain, Patient Global Assessment; MRI synovitis, erosion, bone edema, and combined (synovitis + bone edema) inflammation scores.ResultsRemission was achieved by 172 patients; 100 (58%) and 113 (66%) patients had experienced a flare at WD+6mo and WD+12mo, respectively. In univariate analyses, higher HAQ-DI and MRI synovitis, erosion, bone edema, and combined inflammation scores at WD were identified as potential predictors of flare (P ≤ 0.01). In multivariable analysis, high scores at WD for HAQ-DI and MRI erosion were confirmed as independent predictors of flare at WD+6mo and WD+12mo (P < 0.01).ConclusionIn patients with early RA achieving clinical remission, patient function (HAQ-DI), and MRI measures of bone damage (erosion) predicted disease flare 6 and 12 months after treatment withdrawal. These variables may help identify patients with early RA in clinical remission as candidates for successful treatment withdrawal.Trial registrationClinicalTrials.gov, NCT01142726 (date of registration: June 11, 2010)

Does tenosynovitis of the hand detected by B-mode ultrasound predict loss of clinical remission in rheumatoid arthritis? Results from a real-life cohort.

ObjectiveThe role of US-detected tenosynovitis (USTS) in the management of rheumatoid arthritis remains controversial. The aim of this study was to investigate whether tenosynovitis can predict a flare in rheumatoid arthritis patients in remission in a real-life cohort.MethodsRheumatoid arthritis patients from the Swiss Clinical Quality Management cohort were included in this study if they were in clinical remission, defined by 28-joint disease activity score (DAS28-ESR) <2.6, and had an available B-mode tenosynovitis score. The patients were stratified according to the presence or absence of tenosynovitis (USTS+ vs. USTS–). Cox proportional hazard models were used for time-to-event analysis until the loss of remission, after adjustment for multiple confounders. The impact of baseline US performed early in remission and the advent of flares at different fixed time periods after baseline were investigated in sensitivity analysis.ResultsTenosynovitis was detected in 10% of 402 rheumatoid arthritis patients in remission. At baseline, USTS+ patients in remission had significantly higher DAS28-ESR (mean (SD): USTS– 1.8 (0.5) versus USTS+ 2.0 (0.5); p = 0.0019) and higher additional disease activity parameters, such as physician global assessment, and simplified- and clinical-disease activity index. Joint synovitis detected by B-mode US was associated with tenosynovitis (mean (SD) 7.2 (6.3) in USTS– versus 9.0 (5.4) in USTS+, respectively; p = 0.02). A disease flare was observed in 69% of remission phases, with no differences in the time to loss of remission between USTS+ and USTS– groups.ConclusionWhile US-detected tenosynovitis was associated with higher disease activity parameters in rheumatoid arthritis patients in clinical remission, it was not able to predict a flare.

Ultrasound-detected tenosynovitis as a risk factor for flares in rheumatoid arthritis patients in clinical remission.

Our objective was to investigate the value of ultrasound (US) detected synovitis and tenosynovitis as risk factors for short term flare in rheumatoid arthritis (RA) patients in clinical remission. Consecutive RA patients in clinical remission (DAS28 ERS < 2.6) for at least 3months underwent Power Doppler ultrasound (PDUS) examination of 1st to 6th extensor compartments at the wrist, 2nd to 5th finger flexor, posterior tibial tendon, and peroneal tendons. To assess synovitis, carpal joints, 1st to 5th metacarpophalangeal (MCP) joints, and 2nd to 5th interphalangeal proximal (IPP) joints were bilaterally examined. Synovitis and tenosynovitis were defined according to OMERACT. Patients were followed for 1year. Disease flare was defined as an increase in disease activity generating the need for a change in therapy by the attending rheumatologist. Ninety patients were included. After 1year of follow-up, 26 patients (29%) experienced a flare. At baseline 39%, 23% and 8% had US-detected synovitis, tenosynovitis or both, respectively. In the 1-year period after the baseline US examination, US-detected tenosynovitis (RR: 4.9; 95% CI: 2.2-10.8) was associated with an increased risk of exacerbation. This association was not shown with US-detected synovitis (RR: 1.3; 95% CI: 0.76-2.2). In the multivariate analysis, only subclinical tenosynovitis (OR: 9.8; 95% CI: 2.5-39.1; p = 0.001) and baseline DAS28 (OR: 5.7; 95% CI: 1.1-31.6; p = 0.047) were significantly associated with an increased risk of having a flare. In our study, subclinical tenosynovitis was associated with disease flare in patients with RA in clinical remission. • Synovitis and tenosynovitis are risk factors for short term flare in RA patients in clinical remission. • Subclinical tenosynovitis, but not synovitis, was associated with disease flare in patients with unstable remission. • Ultrasound-detected tenosynovitis could be useful to predict relapses in RA patients in clinical remission.

Ultrasound remission in patients with rheumatoid arthritis in clinical remission.

ObjectivesThe aim of the study was to assess ultrasound (US) remission in patients with rheumatoid arthritis (RA) in clinical remission using different definitions.Material and methodsThis was a cross-sectional study including patients with RA in clinical remission defined by disease activity score (DAS28)-erythrocyte rate (ESR) ≤ 2.6 for at least 6 months. Each patient underwent B-mode and power Doppler (PD) assessments of 42 joints and 20 tendons. B-mode and PD signal for synovitis and tenosynovitis (TS) were defined and graded semi-quantitatively (0–3) according to the outcome measures in rheumatology clinical trials (OMERACT). Several different definitions of US remission were examined: the absence of synovial hypertrophy (SH), TS on B-mode and PD signal, the absence of SH and PD signal, a grade ≤ 1 of SH and the absence of PD, a grade ≤ 1 of SH and PD, the absence of PD, or a grade of PD ≤ 1. The DAS28, clinical disease activity index (CDAI), simple disease activity index (SDAI), and the Boolean American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria were compared.ResultsThirty-seven patients were enrolled. The rate of remission according to the different composite indices was 70.2% for the SDAI, 64.8% for the CDAI, and 54% for the ACR/EULAR Boolean criteria. Synovial hypertrophy and TS in B-mode were detected in 94.6% and 40.5% of patients, respectively. Synovitis with PD signal was found in 59.5% and 13.5% of patients had TS with PD, respectively. Ultrasound remission at joints and tendons was found in 5.4–62.2% of patients. For the other remission criteria: CDAI, SDAI, and ACR/EULAR Boolean criteria, 7.7–60% of patients showed US remission at joints and tendons.ConclusionsClinical remission, even classified by strict composite indices, does not seem to be the closest method to the concept of absence of inflammatory activity; hence the interest of integrating US in assessing remission in practice.

Long-term good outcome of the fibrocavitary form of pulmonary Mycobacterium avium complex disease with concomitant abatacept monotherapy in a patient with rheumatoid arthritis

A 53-year-old woman diagnosed with rheumatoid arthritis (RA) demonstrated thick-walled large cavities with consolidation in the left upper lobe on chest computed tomography (CT). Mycobacterium avium was isolated from sputum cultures, and she was diagnosed as having the fibrocavitary (FC) form of pulmonary Mycobacterium avium complex (MAC) disease. Clarithromycin-containing, multidrug, anti-MAC chemotherapy was started immediately. After 7 months, the cavitary lesions improved, and sputum cultures showed negative conversion. Thereafter, abatacept monotherapy was started due to high RA disease activity. Clinical remission of RA has been sustained and cavitary lesions disappeared by concomitant abatacept and anti-MAC therapy for more than 5 years. Immediate initiation of anti-MAC therapy and prior confirmed efficacy are needed for the treatment of the FC form. Abatacept and anti-MAC therapy could be continued, leading to the withdrawal of prednisolone, along with careful observation by strict chest CT evaluation and repeated sputum cultures. Biologics are generally contraindicated for pulmonary MAC disease, particularly the FC form. When there is a pre-existing lung lesion apparently of FC type, abatacept cannot be started without prior anti-MAC chemotherapy. This case suggests that abatacept may be carefully used to avoid progressive joint destruction after FC lesions of pulmonary MAC disease are resolved.

Subclinical synovitis detected by magnetic resonance imaging and ultrasonography following clinical remission in patients with rheumatoid arthritis: A retrospective study

AbstractBackgroundSubjective residual symptoms persist after clinical remission of rheumatoid arthritis (RA) in Japanese patients. Few studies have examined the relationship between these symptoms and subclinical inflammation using high‐sensitivity imaging (musculoskeletal ultrasound [MSUS] and magnetic resonance imaging [MRI]). We examined the relationship between subjective residual symptoms and imaging findings in patients with RA who achieved clinical remission.MethodsWe enrolled 30 patients with RA. The primary endpoint was the patients' subjective residual symptoms. The secondary endpoint was the relationship between the aforementioned symptoms and imaging findings.ResultsDespite a mean Simplified Disease Activity Index of 1.3, imaging evaluation revealed inflammatory findings. In the multivariate analysis, the Health Assessment Questionnaire Disability Index (HAQ‐DI) and pain visual analog scale (VAS) scores were extracted as independent related factors of subjective residual symptoms. The stratified analysis according to HAQ‐DI showed a significant difference in synovitis on MRI between patients with and without residual disability (12.0 ± 8.7 vs. 5.3 ± 5.3, respectively; p = 0.0192). However, MSUS scores showed no significant difference in these two groups. In addition, no significant differences were found in MSUS and MRI scores between patients with and without residual pain VAS.ConclusionsOur findings demonstrated residual synovitis related to patient‐reported outcomes in patients with RA who achieved clinical remission. In particular, patients with an HAQ‐DI score of &gt;0.25 even after achieving clinical remission should be further examined by MRI and/or MSUS for the evaluation of residual synovitis.

Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region.

BackgroundClinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a cross-sectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region.MethodsRA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission.FindingsA total of 2010 RA patients was included in the study, the overall remission rates were 62•3% (DAS28-CRP), 35•5% (DAS28-ESR), 30•8% (CDAI), 26•5% (SDAI), 24•7% (Boolean), and 17•1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17•9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of GC usage. The favorable related factors were male sex, younger age, fewer comorbidities, fewer extra-articular manifestations (EAM), and use of b/tsDMARDs, while treatment with GC was negatively related to remission.InterpretationRemission rates were low and varied in the Asia-Pacific region. Treatment with b/tsDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region.

Effect of initiating biologics compared to intensifying conventional DMARDs on clinical and MRI outcomes in established rheumatoid arthritis patients in clinical remission: Secondary analyses of the IMAGINE-RA trial

Objectives: To compare the effect of treat-to-target-based escalations in conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics on clinical disease activity and magnetic resonance imaging (MRI) inflammation in a rheumatoid arthritis (RA) cohort in clinical remission. Method: One-hundred patients with established RA, Disease Activity Score based on 28-joint count–C-reactive protein (DAS28-CRP) < 3.2, and no swollen joints (hereafter referred to as ‘in clinical remission’) who received csDMARDs underwent clinical evaluation and MRI of the wrist and second to fifth metacarpophalangeal joints every 4 months. They followed a 2 year MRI treatment strategy targeting DAS28-CRP ≤ 3.2, no swollen joints, and absence of MRI osteitis, with predefined algorithmic treatment escalation: first: increase in csDMARDs; second: adding a biologic; third: switch biologic. MRI osteitis and Health Assessment Questionnaire (HAQ) (co-primary outcomes) and MRI combined inflammation and Simplified Disease Activity Index (SDAI) (key secondary outcomes) were assessed 4 months after treatment change and expressed as estimates of group differences. Statistical analyses were based on the intention-to-treat population analysed using repeated-measures mixed models. Escalation to first biologic compared to csDMARD escalation more effectively reduced MRI osteitis (difference between least squares means 1.8, 95% confidence interval 1.0–2.6), HAQ score (0.08, 0.03–0.1), MRI combined inflammation (2.5, 0.9–4.1), and SDAI scores (2.7, 1.9–3.5). Treat-to-target-based treatment escalations to biologics compared to escalation in csDMARDs more effectively improved MRI inflammation, physical function, and clinical disease activity in patients with established RA in clinical remission. Treatment escalation in RA patients in clinical remission reduces clinical and MRI-assessed disease activity. Trial registration: Clinicaltrials.gov identifier: NCT01656278

Clinical Remission of Rheumatoid Arthritis in a Multicenter Real-World Study in Asia-Pacific Region

Background: Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates in Asia-Pacific region are lacking. We conducted a cross-sectional study to evaluate the clinical remission status and the associated factors in RA patients in Asia-Pacific region. Methods: RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine associated factors of remission. Findings: A total of 2010 RA patients was included in the study, the overall remission rates were 62·31% (DAS28-CRP), 35·51% (DAS28-ESR), 30·78% (CDAI), 26·50% (SDAI), 24·71% (Boolean), and 17·06% (CliDR), respectively, and varied from sites to sites in the 11 countries. Biological disease-modifying antirheumatic drugs (bDMARDs) prescription rate was low (16·9%). Compared to patients in non-remission, patients in remission had higher rates of csDMARDs monotherapy, bDMARDs usage and lower rates of GC usage. The favorable factors were male sex, younger age, fewer comorbidities, less extra-articular manifestations (EAM), and use of bDMARDs, while treatment with GC was negatively associated with remission. Interpretation: Remission rates were low and varied in the Asia-Pacific region. Treatment with bDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region. Funding Information: Beijing Municipal Science and Technology Project (Z191100006619110), Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences. Declaration of Interests: None. Ethics Approval Statement: The study was approved by the ethics committee of each center.

The addition of iguratimod can reduce methotrexate dose in rheumatoid arthritis with clinical remission.

We prospectively evaluated whether the addition of iguratimod (IGU) could sustain clinical remission in rheumatoid arthritis (RA) patients after tapering of methotrexate (MTX). The study included 47 patients; 25 patients in the MTX maintenance group, and 22 patients in the IGU addition group who were treated with additional IGU and tapering of MTX dose. Clinical efficacy and safety were evaluated at 12, 24, and 36weeks. In the IGU addition group, the dose of MTX could be reduced from 8.6 ± 2.4 mg/week at baseline to 4.7 ± 2.2 mg/week at 36 weeks (p < .001). Clinical remission was maintained (disease activity score [DAS]28-ESR 1.48 ± 0.63 at baseline and 1.69 ± 0.76 at 36weeks, p = .911), and disease activity remained low (clinical disease activity index [CDAI] 2.4 ± 1.5 at baseline and 3.1 ± 3.4 at 36weeks, p = .825). The US-GLOSS score significantly decreased from 9.2 ± 5.3 at baseline to 6.4 ± 4.3 at 36weeks (p = .034). In the IGU addition group, two patients discontinued IGU because of stomatitis and three patients relapsed during the follow-up period (flare rate: 15.0%). There was no significant difference in RA disease activity at 36 weeks between the two groups. Additional use of IGU can effectively reduce the MTX dose required by patients during clinical remission without inducing a flare.

Synovitis and Tenosynovitis on Ultrasound as Predictors of DMARD Tapering Failure in Patients with Long-Standing Rheumatoid Arthritis in Clinical Remission or Low Disease Activity.

This study aimed to investigate the predictive value of synovitis and tenosynovitis detected by grayscale (GS) and by power Doppler (PD) ultrasound (US) in relation to failure of tapering disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA) patients. Long-standing RA patients who de-escalated treatment were included in this prospective cohort study. All patients underwent 3 ultrasonographic and clinical assessments, at baseline and every 3 or 4 months, over a period of 6-8 months. US investigation of 32 joints was performed. Synovitis was assessed by GS and PD semiquantitative scoring (0-3) and a global score was calculated for each individual by summing single joint scores. The presence of tenosynovitis was recorded whenever detected during ultrasound assessment. Thirty-three patients completed the follow-up period (29 women; 4 men). Eight patients (25%) relapsed. Using the optimal cutoff values determined by receiver operating characteristic curve, patients with a PD synovitis ≥1 at baseline had significantly greater chances to relapse than those without PD activity. During follow-up, GS tenosynovitis was detected in 6 patients (5 with PD) who failed and in 3 patients (1 with PD) who succeeded in tapering therapy. Having at least 1 joint with PD synovitis resulted in a relative risk of 3.14 and having GS tenosynovitis resulted in a relative risk of 11.4 (95% CI: 1.03-9.60 and 2.82-45.9, respectively) for relapse in the multivariate Poisson model. PD synovitis and GS tenosynovitis may be useful to identify RA patients in risk of relapse after DMARD tapering.