Tight Control Strategy Research Articles

P471 Tight control strategy improves combined histologic and endoscopic remission in ulcerative colitis

Abstract Background Increasing evidence suggests that combined histological and endoscopic remission associates with less adverse outcomes (hospitalization and corticosteroid therapy) and predicts a quiescent course of ulcerative colitis (UC). However, few patients can achieve this target with the drugs currently available. A tight control strategy with a proactive treatment escalation based on biomarkers may improve these results. Methods Retrospective, single-center cohort study including consecutive patients with UC with severe endoscopic disease (Mayo endoscopic subscore=3) and subsequent endoscopic, histologic and faecal calprotectin (FCP) evaluation. Data concerning demographic, disease phenotype, laboratory findings and treatment were collected. We defined tight control strategy as therapeutic escalation in >50% of cases where FCP≥250ug/g. Therapeutic escalation was defined as the start, switch or dose increment/interval shortening of biologic therapies/small molecules. Endoscopic remission was defined as a Mayo endoscopic subscore ≤1. Histologic remission was defined as the absence of ulcers, erosions and neutrophils in the lamina propria. Results One hundred and seven patients were included, 56.0% male and 63.6% with extensive UC. Thirty-four patients (31.8%) were included in the tight control group. During follow up, 52 patients (48.6%) achieved endoscopic remission, 29 (27.1%) histological remission and 27 (25.1%) combined remission. Patients in the tight control group achieved combined remission more frequently (38.2 vs 19.2%, P=0.05). On multivariate analysis including age at diagnosis, duration and extension of disease and therapy received, a tight control strategy was independently related to a higher probability of combined remission: OR 2.768 IC95% 1.056-7.255, P=0.038. Conclusion A tight control strategy based on FCP was associated with higher combined histological and endoscopic remission in UC.

Intestinal ultrasound as a non-invasive tool to monitor inflammatory bowel disease activity and guide clinical decision making

Intestinal ultrasound (IUS) is a non-invasive, real-time, cross-sectional imaging tool that can be used at the point-of-care to assess disease activity in patients with Crohn's disease or ulcerative colitis. IUS promotes quick and impactful treatment decisions that can modify disease progression and enhance patient compliance. This review will summarize the technical aspects of IUS, the evidence to support the use of IUS in disease activity monitoring, the comparison of IUS to current standard of care monitoring modalities such as colonoscopy and calprotectin, and the optimal positioning of IUS in a tight-control monitoring strategy.

Prediction of Dry-Low Emission Gas Turbine Operating Range from Emission Concentration Using Semi-Supervised Learning.

Dry-Low Emission (DLE) technology significantly reduces the emissions from the gas turbine process by implementing the principle of lean pre-mixed combustion. The pre-mix ensures low nitrogen oxides (NOx) and carbon monoxide (CO) production by operating at a particular range using a tight control strategy. However, sudden disturbances and improper load planning may lead to frequent tripping due to frequency deviation and combustion instability. Therefore, this paper proposed a semi-supervised technique to predict the suitable operating range as a tripping prevention strategy and a guide for efficient load planning. The prediction technique is developed by hybridizing Extreme Gradient Boosting and K-Means algorithm using actual plant data. Based on the result, the proposed model can predict the combustion temperature, nitrogen oxides, and carbon monoxide concentration with an accuracy represented by R squared value of 0.9999, 0.9309, and 0.7109, which outperforms other algorithms such as decision tree, linear regression, support vector machine, and multilayer perceptron. Further, the model can identify DLE gas turbine operation regions and determine the optimum range the turbine can safely operate while maintaining lower emission production. The typical DLE gas turbine's operating range can operate safely is found at 744.68 °C -829.64 °C. The proposed technique can be used as a preventive maintenance strategy in many applications involving tight operating range control in mitigating tripping issues. Furthermore, the findings significantly contribute to power generation fields for better control strategies to ensure the reliable operation of DLE gas turbines.

Prevalence and predictors of long-term remission in rheumatoid arthritis in real-world practice: a longitudinal study.

The aim of the present study was to provide real-world evidence for factors predicting long-term remission in a longitudinal study of rheumatoid arthritis (RA) patients. Long-term remission was defined by meeting American Rheumatism Association (ARA) criteria for remission and prednisolone dose ≤ 5mg/d for at least 5years. Patients in this cohort were treated by tight control strategy using step-up combination therapy with conventional synthetic DMARDs (csDMARDs), biologic DMARDs. The parameters associated with long-term remission were subjected to univariate analysis, and parameters with P-values of < 0.1 in univariate analysis were included in a multivariate regression analysis. One thousand two hundred and eighty-six RA subjects were considered for eligibility, and finally, 499 patients were included in the study. Median duration of follow-up was 108months. Long-term remission occurred in 157 (31.5%) patients. Median time to long-term remission was 8 (5, 41) months. Predictors of long-term remission were absence of flare during the course of disease, occurrence of sustained remission during 6months after starting therapy, age at the disease onset > 60, being anti-citrullinated protein antibodies (ACPA) negative, and Disease Activity Score-28 (DAS28) at cohort entry ≤ 5.1. In real-world practice, long-term remission occurs in 31.5% of patients treated with a tight control strategy. Absence of flare during the course of disease, occurrence of sustained remission during 6months after starting therapy, age at the disease onset > 60, being ACPA negative, and DAS28 at baseline ≤ 5.1 are independent predictors of long-term remission. Key Points • In real-world practice, long-term remission occurs in 31.5% of patients treated with a tight control strategy. • Median time to long-term remission was 8months. • Absence of flare during the course of disease, occurrence of sustained remission during 6months after starting therapy, age at the disease onset >60, being ACPA negative, and DAS28 at baseline ≤ 5.1 are independent predictors of long-term remission.

P653 Tight control and Treat to target increase the rates of Transmural remission and Transmural response in Crohn’s disease

Abstract Background increasing evidence support the use of Transmural remission as a treatment target in Crohn’s disease (CD) but few patients can reach it with currently available therapies. Treat-To-Target (T2T) and Tight-Control (TC) strategies may potentially improve these results. Methods Methods: single-center retrospective study including 123 CD patients with active colonoscopy (CN) and magnetic resonance enterography (MRE) at baseline and with available follow-up CN and MRE for reassessment of remission. We evaluated the effects of T2T and TC strategies on the rates of Transmural remission and Transmural response. Patient submitted to bowel surgery between examinations were excluded. Definitions CN activity: ulcers in non-operated patients or Rutgeerts score&amp;gt; i1 in operated patients; MRE activity: bowel thickness &amp;gt;3 mm and enhancement on T1/T2 sequences. Transmural remission: inactive CN and MRE at reassessment; Transmural response: improvement from baseline in either examination. T2T: treatment decisions resulting in both clinical remission (Harvey-Bradshaw &amp;lt;5) and fecal calprotectin remission (Fc &amp;lt;250 ug/g) at reassessment. TC: treatment decisions resulting in persistent Fc remission (≥ 2 consecutive results, including reassessment). Results 48.0% and 42.3% of patients followed a T2T and TC strategy, respectively. Transmural remission and Transmural response were reached by 33.3% and 69.1% of patients, respectively. T2T resulted in higher rates of Transmural remission (55.9% vs 12.5%, P&amp;lt;0.001) and Transmural response (91.5% vs 48.4%, P&amp;lt;0.001). TC was also associated with higher rates of Transmural remission (51.9% vs 19.7%, P&amp;lt;0.001) and Transmural response (90.4% vs 53.5%, P&amp;lt;0.001). In multivariate regression, T2T (OR 9.30 95%CI 2.85-30.30, P&amp;lt;0.001), TC (OR 3.85 95%CI 1.18-12.54, P=0.025) and starting biologic treatment (OR 3.63 95%CI 1.36-9.70, P=0.010) were independent predictors of reaching Transmural response. T2T was the only independent predictor of reaching Transmural remission (OR 6.540 95%CI 2.41-17.74, P&amp;lt;0.001). Conclusion Patients following a T2T and TC strategy presented higher rates of Transmural remission and Transmural response.

A treat-to-target approach is needed for Behçet's syndrome.

Treat-to-target (T2T) approach has improved outcomes in chronic diseases. The aim of this review is to discuss the long-term goals and review the evidence for possible targets that would predict the achievement of these goals for developing a T2T strategy for Behçet's syndrome. There are no trials comparing a tight control strategy to standard care in Behçet's syndrome but recent studies suggest better outcomes with earlier use of biologic agents compared with sustained conventional treatment. Fluorescein angiography may be a reliable tool for assessing remission in uveitis as fluorescein angiography findings were shown to predict relapses and long-term visual outcome. Good recanalization on Doppler ultrasonography can be a target for venous involvement as this was the only predictor of relapse. Fecal calprotectin levels were associated with small intestinal and colonic ulcers and may be used as a surrogate for remission of gastrointestinal involvement. There are several new treatment modalities that are tried for Behçet's syndrome and ongoing work on outcome measures for reliable disease assessment. In order to ensure the wise and efficient use of treatment modalities, development and implementation of T2T strategies are needed through multidisciplinary and multinational efforts that include patient research partners.

Treatment of palindromic rheumatism: A systematic review.

Palindromic rheumatism (PR) characterised by self-resolving attacks of arthritis and peri-arthritis that may progress to other autoimmune connective tissue diseases (CTDs). The aim of this systematic review was to analyse the effectiveness of different treatments on PR. Articles were collected from Cochrane, PubMed, Science Direct, Scopus, ProQuest, Ebsco, Google Scholar, MEDLINE and EMBASE. Search keywords were "palindromic rheumatism," "palindromic rheumatism and remission," "palindromic rheumatism and course," "palindromic rheumatism and prognosis," "palindromic rheumatism and treatment" and "palindromic rheumatism and therapy." The studies that were included met the following criteria: (a) adult patients aged ≥16 with PR; (b) being on treatment with medications defined as those that were developed for the treatment of inflammatory arthritis and (c) including outcome measures to evaluate the efficacy of the treatment including remission rate and progression to other diseases. Twenty-four studies met the inclusion criteria. Although case series and retrospective studies showed that conventional disease-modifying antirheumatic drugs (DMARDs) can control attacks of the disease, 15%-70% of patients with PR evolve to autoimmune CTDs during several years, despite treatment with DMARDs. A retrospective study showed that tight control strategy could control attacks of the disease and prevent its progression to RA. The evidence provided from available studies is insufficient to determine that DMARDs can prevent the progression of PR to autoimmune CTDs. Although case series and retrospective studies showed that DMARDs can control attacks of the disease, our review suggests that randomised clinical trials and prospective studies with adequate sample size are needed to prove that DMARDs can prevent progression of PR to autoimmune CTDs and which DMARDs are preferred for the treatment of PR.

Telemedicine in rheumatology: high specificity and sensitivity of follow-up virtual video consultations during COVID-19 pandemic.

ObjectiveTo evaluate the reliability of virtual video-assisted visits, added to the tight control strategy for inflammatory rheumatic diseases (IRDs), in identifying patients that need treatment adjustment.MethodsTightly followed-up adult patients with rheumatoid arthritis, psoriatic arthritis (PsA), ankylosing spondylitis, and systemic lupus erythematosus (SLE) performed a video consultation during COVID19 lockdown and repeated the same rheumatology evaluations through a face-to-face visit within 2-weeks. Sensitivity and specificity of virtual visits for treatment decisions (categorized as unchanged, adjusted/escalate, tapered/discontinued, need for further examinations), and the intraclass correlation coefficient (ICC) for virtually measured disease activity and patient-reported outcomes (PROs) were calculated with 95% confidence interval (95%CI) using face-to-face visits as the reference method.ResultsIn 89 out of 106 (84.0%) patients, face-to-face visits confirmed the remotely delivered treatment decision. Video-visiting showed excellent sensitivity (94.1% with 95%CI 71.3%-99.9%) and specificity (96.7%; 95%CI 90.8% to 99.3%) in identifying the need for treatment adjustment due to inadequate disease control. The major driver for the low sensitivity of virtual video consultation (55.6%; 95%CI 21.2%-86.3%) in identifying the need for treatment tapering was SLE diagnosis (OR 10.0; 95%CI 3.1-32.3; p < 0.001), mostly because of discordance with face-to-face consultation in glucocorticoid tapering. Remotely evaluated PROs showed high reliability (ICC range 0.80 to 0.95) whilst disease activity measures had less consistent data (ICC range 0.50 to 0.95), especially those requiring more extensive physical examination such as in SLE and PsA.ConclusionVideo-visiting proved high reliability in identifying the need for treatment adjustment and might support the IRDs standard tight-control strategy.

Can treating rheumatoid arthritis with disease-modifying anti-rheumatic drugs at the window of opportunity with tight control strategy lead to long-term remission and medications free remission in real-world clinical practice? A cohort study.

The aim of this retrospective study is to compare the results of starting rheumatoid arthritis (RA) treatment with tight control strategy in the window of opportunity and later phases of the disease in real-world clinical practice. In this cohort, 609 RA patients were divided into three groups: (i) very early treatment (VET): ≤ 3months; (ii) early treatment (ET): 3-12months; and (iii) late treatment (LT) > 12months after the onset of the disease. Four levels of remission were defined: (i) sustained remission on treatment, (ii) sustained glucocorticoids free remission, (iii) sustained disease-modifying anti-rheumatic drugs (DMARDs) free remission, and (iv) long-term remission. Outcome was assessed based on the number of patients in sustained or long-term remission and patients with poor joint outcome and systemic involvement. There were no significant differences in the remission rate between the groups. Time to sustained remission in VET group was shorter than ET and LT groups. There were no significant differences in the rate and duration of prednisolone discontinuation in the studied groups. DMARDs were discontinued in VET, ET, and LT groups in 8.7%, 10.2%, and 7% of the patients, respectively. Poor joint outcome occurred in 33.2%, 50.5%, and 59.4% of the patients in the VET, ET, and LT groups, respectively. Remission induction in the first year of the treatment was associated with long-term remission in the VET, ET, and LT groups. Medications free remission in RA is rare, and although treatment with DMARDs within 3months of the onset of the disease can prevent joint damage, it cannot lead to long-term remission and discontinuation of medications. • Medications free remission in rheumatoid arthritis is rare. • Treatment with DMARDs within 3months of the onset of the disease can prevent joint damage, but it cannot lead to long-term remission and discontinuation of medications.

Efficacy of tight control strategy in the treatment of adult-onset Still disease.

Adult-onset Still's disease (AOSD) characterized by a high spiking fever, skin rash, arthritis, and leukocytosis. The aim of the present study was considering the long-term outcomes of patients with AOSD who were treated with tight control strategy with disease modifying anti-rheumatic drugs (DMARDs). Fifty-six patients with AOSD treated with tight control strategy were included. Four levels of remission were defined. Remission on-treatment was defined as the clinical remission, patient global assessment (PGA) ≤ 1, and prednisolone dose ≤ 5mg/day for at least 6months. Remission off-treatment was defined as the clinical remission and PGA ≤ 1 for at least 6months as well as discontinuation of prednisolone, DMARDs, and biologics. Sustained remission on-treatment was defined as the clinical remission, PGA ≤ 1, and prednisolone dose ≤ 5mg/day for ≥ 5years. Sustained remission off-treatment was defined as the clinical remission and PGA ≤ 1 for ≥ 5years as well as discontinuation of prednisolone, DMARDs, and biologics. Throughout a median follow-up of 47months, remission on-treatment and off-treatment were obtained in 94.6% and 44.6% of patients, respectively. Sustained remission on-treatment and off-treatment were obtained in 79.2 and 8.3% of patients, respectively. Glucocorticoids (GCs) and DMARDs were discontinued in 66.1% and 48.2% of the patients, respectively. Apart from the older age of the patients in the on-GCs group, no significant differences were observed between the groups. Our study showed that using DMARDs with tight control strategy at the presentation of AOSD may control disease activity successfully. Key Points • Using DMARDs with tight control strategy at the presentation of adult-onset Still's disease may control disease activity successfully.

Relation of the Serum Levels of DKK-1 and Osteoprotegerin with Bone Mass in Tightly Controlled Rheumatoid Arthritis.

To analyze the association between serum levels of osteoprotegerin (OPG) and Dickkopf-related protein 1 (DKK-1) and the annual percent change (Δ%) in bone mineral density (BMD) in patients with tightly controlled rheumatoid arthritis (RA). Observational mixed-study. RA patients followed-up with a tight-control strategy were included. Bone densitometries were performed at baseline (T0) and follow-up (T1) and serum levels of OPG and DKK-1 were measured by ELISA also in T0 and T1; additional clinical variables included disease activity measures, and treatment for RA and osteoporosis. Descriptive bivariate and multivariate analyses, stratified by gender, were performed. We included 97 RA patients (70% female, with a mean age of 53 years, and 76% with low activity by DAS28); 95% were treated with DMARDs and 37% with anti-osteoporotic drugs. Mean time between T0 and T1 was 2.7 years. Most patients had their BMD improved. The mean Δ%BMD was +0.42% for lumbar spine, +0.15% for femoral neck and +0.91% for total femur. In men, baseline OPG was significantly associated with higher BMD loss (β coefficient -0.64) at the femoral neck. In women, DKK-1 was associated with higher BMD loss at the femoral neck (β coefficient -0.09), and total femur (β coefficient -0.11); however, DKK-1 was associated with lower BMD loss at the lumbar spine (β coefficient 0.06). In tightly controlled RA patients, we have found no evidence of bone loss. The role of DKK1 and OPG seems small and might be related to sex and location.

Is Palindromic Rheumatism a Pre-rheumatoid Arthritis Condition? Low Incidence of Rheumatoid Arthritis in Palindromic Rheumatism Patients Treated with Tight Control Strategy

ObjectivesPalindromic rheumatism (PR) is characterized by repetitive, afebrile episodes of acute arthritis and peri-arthritis. The aim of this study was considering the long-term outcomes of patients with PR who were treated with tight control strategy using Disease-modifying anti-rheumatic drugs (DMARDs). MethodsWe reviewed the charts of 106 patients diagnosed with PR who were referred to the Connective Tissue Diseases Research Center (CTDRC). We recruited all the patients diagnosed with PR according to the criteria of Hannonen. They visited the CTDRC clinic regularly and were treated with hydroxychloroquine and low dose prednisolone because of active episodes of PR. In cases that the attacks did not come under control in 3–6 months, methotrexate was added or replaced and the dose was increased up to 25mg/week. In resistant cases, sulfasalazine was added, followed by the addition of leflunomide and then azathioprine. Disease outcome was evaluated by getting complete or partial remission and prevention of disease evolution to rheumatoid arthritis (RA) or other inflammatory connective tissue diseases. ResultsThis study included 92 patients with PR who were treated with DMARDs. Attacks were controlled completely or partially in 76 (82.6%) patients. Medications free remission was obtained in 16.3% of the patients. RA developed in 8.7% of the patients. By multivariate logistic regression analysis, age ≤40 at disease presentation, non-adherence to therapy and PIP joints involvement were the only factors which independently predicted the risk of treatment failure. ConclusionsTight control strategy by using DMARDs may control PR and prevent disease progression to RA.

Use of Small Bowel Ultrasound to Predict Response to Infliximab Induction in Pediatric Crohn's Disease.

The goal of this study was to explore the utility of small bowel ultrasound (SBUS) as a noninvasive tool to assess induction response to infliximab (IFX) in pediatric Crohn's disease (CD). Inflammatory bowel disease management has shifted to a treat-to-target and tight control strategy utilizing noninvasive serum and fecal markers to monitor disease activity in response to therapy. Bowel wall changes as seen on cross-sectional imaging may be a more accurate marker of treatment success. Pediatric patients with CD with small bowel involvement initiating IFX were prospectively enrolled. Clinical activity, biomarkers, and SBUS findings were evaluated at baseline (T0) and postinduction at week 14 (T1). The primary outcome was to describe the changes in SBUS parameters pre and post IFX induction and how they associate with clinical and biomarker response. Descriptive statistics summarized the data and univariate analysis tested associations. All 13 CD patients achieved steroid-free clinical remission (P<0.001) and a decrease in C-reactive protein (P=0.01) postinduction. Bowel wall hyperemia (BWH) (P=0.01) and bowel segment length involved (P=0.07) decreased postinduction. Decrease in fecal calprotectin at T1 moderately correlated with a decrease in bowel segment length (r=0.57; P=0.04). No correlation was seen with a change in bowel wall thickness or BWH postinduction. Our pilot study suggests that SBUS is a feasible, noninvasive tool to measure early treatment response to IFX. BWH, not bowel wall thickness, is the first parameter to change. Larger longitudinal studies are warranted to validate the utility of SBUS as part of a disease monitoring strategy.

Deep Remission at 1 Year Prevents Progression of Early Crohn’s Disease

We investigated the effects of inducing deep remission in patients with early Crohn's disease (CD). We collected follow-up data from 122 patients (mean age, 31.2 ± 11.3 y) with early, moderate to severe CD (median duration, 0.2 years; interquartile range, 0.1-0.5) who participated in the Effect of Tight Control Management on CD (CALM) study, at 31 sites, representing 50% of the original CALM patient population. Fifty percent of patients (n= 61) were randomly assigned to a tight control strategy (increased therapy based on fecal level of calprotectin, serum level of C-reactive protein, and symptoms), and 50% were assigned to conventional management. We categorized patients as those who were vs were not in deep remission (CD endoscopic index of severity scores below 4, with no deep ulcerations or steroid treatment, for 8 or more weeks) at the end of the follow-up period (median, 3.02 years; range, 0.05-6.26 years). The primary outcome was a composite of major adverse outcomes that indicate CD progression during the follow-up period: new internal fistulas or abscesses, strictures, perianal fistulas or abscesses, or hospitalization or surgery for CD. Kaplan-Meier and penalized Cox regression with bootstrapping were used to compare composite rates between patients who achieved or did not achieve remission at the end of the follow-up period. Major adverse outcomes were reported for 34 patients (27.9%) during the follow-up period. Significantly fewer patients in deep remission at the end of the CALM study had major adverse outcomes during the follow-up period (P= .01). When we adjusted for potential confounders, deep remission (adjusted hazard ratio, 0.19; 95% confidence interval, 0.07-0.31) was significantly associated with a lower risk of major adverse outcome. In an analysis of follow-up data from the CALM study, we associated induction of deep remission in early, moderate to severe CD with decreased risk of disease progression over a median time of 3 years, regardless of tight control or conventional management strategy.

Treatment strategies are more important than drugs in the management of rheumatoid arthritis.

The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.

Conventional versus ultrasound treat to target: no difference in magnetic resonance imaging inflammation or joint damage over 2 years in early rheumatoid arthritis.

To investigate whether an ultrasound-guided treat-to-target strategy for early RA would lead to reduced MRI inflammation or less structural damage progression compared with a conventional treat-to-target strategy. A total of 230 DMARD-naïve early RA patients were randomized to an ultrasound tight control strategy targeting DAS <1.6, no swollen joints and no power Doppler signal in any joint or a conventional strategy targeting DAS <1.6 and no swollen joints. Patients in both arms were treated according to the same DMARD escalation strategy. MRI of the dominant hand was performed at six time points over 2 years and scored according to the OMERACT RA MRI scoring system. A total of 218 patients had baseline and one or more follow-up MRIs and were included in the analysis. The mean MRI score change from baseline to each follow-up and the 2 year risk for erosive progression were compared between arms. MRI bone marrow oedema, synovitis and tenosynovitis improved over the first year and was sustained during the second year of follow-up, with no statistically significant differences between the ultrasound and the conventional arms at any time point. The 2 year risk for progression of MRI erosions was similar in both treatment arms: ultrasound arm 39%, conventional arm 33% [relative risk 1.16 (95% CI 0.81, 1.66), P = 0.40]. Incorporating ultrasound information in treatment decisions did not lead to reduced MRI inflammation or less structural damage compared with a conventional treatment strategy. The findings support that systematic use of ultrasound does not provide a benefit in the follow-up of patients with early RA. Clinicaltrials.gov, http://clinicaltrials.gov, NCT01205854.

P458 Association between adalimumab serum levels and level of remission in Crohn’s disease

Abstract Background Adalimumab (ADA) is effective as induction and maintenance therapy in Crohn’s disease (CD). Serum ADA levels have been shown to be correlated with clinical remission. Therapeutic goals have evolved based on the notion of ‘treat to target’ and the aim is to achieve deep remission. The objective of this study was to consider the association between serum ADA levels and clinical, biological, endoscopic and iconographic remission in CD. Methods From October 1, 2016 to December 31, 2018, all CD patients receiving ADA who had a serum ADA level test with anti-ADA antibodies (AAA) detection were consecutively included. We compared serum ADA levels between the following groups: patients with and without clinical remission, patients with biological remission and those with a CRP &amp;gt;5mg/l, patients with endoscopic remission and those with ulcerations and patients with iconographic remission and those with active radiological lesions. In addition, we defined optimal cut-off values to reach these therapeutic targets by analysing ROC curves. Results Three hudred and four patients were included corresponding to a total of 445 assays. Indications for the ADA assay were mainly for persistent disease activity in 308 (69%) samples. An immunosuppressant was initially associated with ADA treatment in 154 (35%) samples and 75 (17%) assays were performed under combotherapy. ADA concentrations were higher in patients who started ADA in combotherapy (8.3 vs. 6.6 μg/ml, p = 0.005), but not in patients treated by combotherapy at the time of dosing (8.7 vs. 7.1 μg/ml, p = 0.12). Serum levels of ADA were significantly higher in patients in remission compared with patients with active disease for clinical remission (7.9 vs. 6.3 μg/ml, p = 0.015), biological remission (9.5 vs. 5.1 μg/ml, p &amp;lt;0.001), endoscopic remission (10.1 vs. 6.1 μg/ml, p &amp;lt;0.001) and luminal iconographic remission (9.1 vs. 6.8 μg/ml, p = 0.04). ROC curves and the areas under the curve (ASC) were analysed to determine optimal cut-off values of serum ADA levels to predict these different levels of remission: 6.45 μg/ml (AUC 0, 56, p = 0.027) for clinical remission, 7.35 μg/ml (AUC 0.67, p &amp;lt; 0.001) for biological remission, 9.75 μg/ml (AUC 0.64, p = 0.002) for endoscopic remission and 7.80 μg/ml (AUC 0.58, p = 0.04) for luminal iconographic remission. Conclusion High levels of ADA are associated with clinical, biological, endoscopic and iconographic remission in CD. Optimal cut-off values of ADA have been identified and increase as deep remission is obtained. These results suggest that serum ADA levels should be considered to be one of the tools in the tight control strategy of CD and adapted according to pre-defined objectives (clinical, biological or mucosal).

Tight control for Crohn’s disease with adalimumab-based treatment is cost-effective: an economic assessment of the CALM trial

ObjectiveTo evaluate the cost-effectiveness of an inflammatory biomarker and clinical symptom directed tight control strategy (TC) compared with symptom-based clinical management (CM) in patients with Crohn’s disease (CD) naïve to...

Is Palindromic Rheumatism a Pre-rheumatoid Arthritis Condition? Low Incidence of Rheumatoid Arthritis in Palindromic Rheumatism Patients Treated with Tight Control Strategy.

Palindromic rheumatism (PR) is characterized by repetitive, afebrile episodes of acute arthritis and peri-arthritis. The aim of this study was considering the long-term outcomes of patients with PR who were treated with tight control strategy using Disease-modifying anti-rheumatic drugs (DMARDs). We reviewed the charts of 106 patients diagnosed with PR who were referred to the Connective Tissue Diseases Research Center (CTDRC). We recruited all the patients diagnosed with PR according to the criteria of Hannonen. They visited the CTDRC clinic regularly and were treated with hydroxychloroquine and low dose prednisolone because of active episodes of PR. In cases that the attacks did not come under control in 3-6 months, methotrexate was added or replaced and the dose was increased up to 25mg/week. In resistant cases, sulfasalazine was added, followed by the addition of leflunomide and then azathioprine. Disease outcome was evaluated by getting complete or partial remission and prevention of disease evolution to rheumatoid arthritis (RA) or other inflammatory connective tissue diseases. This study included 92 patients with PR who were treated with DMARDs. Attacks were controlled completely or partially in 76 (82.6%) patients. Medications free remission was obtained in 16.3% of the patients. RA developed in 8.7% of the patients. By multivariate logistic regression analysis, age ≤40 at disease presentation, non-adherence to therapy and PIP joints involvement were the only factors which independently predicted the risk of treatment failure. Tight control strategy by using DMARDs may control PR and prevent disease progression to RA.

Tight control: a new therapeutic strategy in the management of osteoporotic patients.

We intended to ascertain whether tight control (i.e., follow-up visits and bone turnover markers/BTM/and parathyroid hormone/PTH/monitoring at 3-month intervals) strategy achieves a statistically greater increase in bone mineral density over the observation period than standard follow-up care (i.e., bone densitometry at 1-year intervals, without BTM monitoring). We studied involutional osteoporotic patients newly enrolled into chronic care. One hundred and eleven patients underwent tight control, while another 113 received routine treatment (with follow-up visits scheduled at > 1-year intervals). We compared the changes in bone mineral density reflected by the results of bone mineral density (BMD) measurements of the lumbar spine and of the left femoral neck. Statistical analyses were performed with version 22 of the SPSS software package. In the group of patients under tight control, baseline and follow-up median BMD values were 0.842/0.881g/cm2 at the L1-4 vertebrae and 0.745/0.749g/cm2 at the femoral neck. In the group under routine care, the corresponding values were 0.903/0.915g/cm2 and 0.742/0.72g/cm2, respectively. The relative changes of the bone mineral density of the femoral neck was significantly (p = 0.041) higher in patients under tight control than in those receiving routine care; however, BMD changes in the lumbar spine were not statistically different. Our findings suggest that adopting tight control as a new therapeutic strategy might be justified in the osteoporosis management. In fact, a greater improvement of BMD can be achieved by treatment according to these principles.