Tight Control Treatment Strategy Research Articles

Treat to Target in Psoriatic Arthritis.

A treat-to-target approach to psoriatic arthritis has emerged as a topic of interest following successful application of this treatment paradigm to rheumatoid arthritis. In psoriatic arthritis, this has been examined in one randomized trial to date showing benefits of a tight control treatment strategy over standard care. Nonetheless, international treatment recommendations have called for clinicians to aim for a target of remission or low disease activity, although little or no consensus exists on how to measure these targets. An ideal measure to define a treatment target should be able to address all the disease domains and preferences pertinent to an individual patient.

Effect of Treat-to-target Strategies Aiming at Remission of Arterial Stiffness in Early Rheumatoid Arthritis: A Randomized Controlled Study.

To determine the efficacy of 2 tight control treatment strategies aiming at Simplified Disease Activity Score (SDAI) remission (SDAI ≤ 3.3) compared to 28-joint count Disease Activity Score (DAS28) remission (DAS28 < 2.6) in the prevention of arterial stiffness in patients with early rheumatoid arthritis (RA). This was an open-label study in which 120 patients with early RA were randomized to receive 1 year of tight control treatment. Group 1 (n = 60) aimed to achieve SDAI ≤ 3.3 and Group 2 (n = 60), DAS28 < 2.6. Pulse wave velocity (PWV) and augmentation index (AIx) were measured at baseline and 12 months. A posthoc analysis was also performed to ascertain whether achieving sustained remission could prevent progression in arterial stiffness. The proportions of patients receiving methotrexate monotherapy were significantly lower in Group 1 throughout the study period. At 12 months, the proportions of patients achieving DAS28 and SDAI remission, and the change in PWV and AIx, were comparable between the 2 groups. In view of the lack of differences between the 2 groups, a posthoc analysis was performed at Month 12, including all 110 patients with PWV, to elucidate the independent predictors associated with the change in PWV. Multivariate analysis revealed that achieving sustained DAS28 remission at months 6, 9, and 12 and a shorter disease duration were independent explanatory variables associated with less progression of PWV. With limited access to biologic disease-modifying antirheumatic drugs, treatment efforts toward DAS28 and SDAI remission had similar effects in preventing the progression of arterial stiffness at 1 year. However, achieving sustained DAS28 remission was associated with a significantly greater improvement in PWV. [Clinical Trial registration: Clinicaltrial.gov NCT01768923.].

Effect of treat-to-target strategies on bone erosion progression in early rheumatoid arthritis: An HR-pQCT study.

To investigate the efficacy of two tight-control treatment strategies aimed at simplified disease activity score [SDAI] remission (SDAI ≤ 3.3) compared to DAS28 remission (DAS28 < 2.6) on progression of bone erosions in early rheumatoid arthritis (ERA) patients using high-resolution peripheral quantitative computed tomography (HR-pQCT). This was an open-label study in which 80 early RA patients were randomized to receive 1-year of tight-control treatment. Group 1 (n = 37) aimed at SDAI ≤ 3.3 and group 2 (n = 43) aimed at DAS28-CRP < 2.6. The number and size of bone erosions, as well as the bone mineral density (BMD) surrounding bone erosion at the second metacarpophalangeal joint (MCP2), were measured at baseline and 12 months. After 12 months, images were analyzed in 63 patients. Changes in clinical parameters, number and size of bone erosions as well as the BMD surrounding bone erosion between the two treatment groups were similar. Therefore, a post-hoc analysis including all 63 patients was performed to elucidate the independent predictors of erosion progression and repair. Multivariate analysis revealed that not achieving sustained SDAI remission at month 6, 9 and 12 (p = 0.034) and rheumatoid factor >16U (p = 0.021) were independent predictors associated with an increase in erosion volume. Logistic regression analysis showed that achieving sustained SDAI remission (p = 0.043) was associated with partial erosion repair. Although more stringent treatment target did not notably affect clinical treatment outcome and erosion progression at 1 year, achieving sustained SDAI remission was found to be associated with partial erosion repair.

Determining the Lowest Optimally Effective Methotrexate Dose for Individual RA Patients Using Their Dose Response Relation in a Tight Control Treatment Approach.

ObjectiveTo determine the optimal methotrexate dose in individual patients and to explore whether this optimal dose and the level of disease activity at that dose could be predicted.MethodsData from CAMERA II trial comparing MTX and MTX with 10 mg of prednisone both in a tight control treatment strategy in early RA was used. For each patient a curve for disease activity over time was fitted and the MTX dose after which further step-up did not result in relevant improvement in disease activity anymore was determined the 'lowest optimally effective MTX dose (LOED)'. The association of demographic and clinical characteristics at baseline with this LOED and with the level of disease activity reached at LOED was studied.ResultsIn 204 (100 MTX and 104 MTX with prednisone) out of 236 patients LOED could be defined. 10 mg/wk was the most prevalent LOED in patients treated with MTX and prednisone and 10 mg/wk, 20 mg/wk and 30 mg/wk in the MTX strategy. Although the specific LOED could not reliably be predicted, higher baseline disease activity, height and lower weight were associated with higher LOEDs (i.e at least 15 mg/wk). A score was presented to decide on a starting dose of 10 mg/wk or (at least) 15 mg/wk. The level of disease activity at LOED could not be reliably predicted.ConclusionA starting dose of 10 mg/wk might be a good choice for most patients and is frequently already the optimal dose. However, a subgroup of patient can be determined who would require higher MTX doses.

SAT0088 Economic Evaluation of A Tight-Control Treatment Strategy Using an Imaging Device (HANDSCAN) for Monitoring Joint Inflammation in Early Rheumatoid Arthritis

BackgroundNowadays treat-to-target by means of tight-control is generally accepted as the standard treatment principle in early rheumatoid arthritis (RA) (Schoels et.al.). However, this requires frequent (monthly) visits including comprehensive clinical...

SAT0060 Tight Control Schedules Could be a Burden to Patients with Early RA, but they do not Negatively Impact the Improved Quality of Life Via Decreased Disease Activity - Results from the Camera Trials

BackgroundTight control with treat-to-target as treatment strategy is widely used to prevent a severe outcome of rheumatoid arthritis (RA). Our CAMERA (Computer Assisted Management of Early Rheumatoid Arthritis)1 study demonstrated...

AB0315 Effect of prednisone on quality of life domains in early rheumatoid arthritis - additional analyses of the camera-ii-trial -

BackgroundIn the Computer Assisted Management in Early RA trial-II (CAMERA II), addition of 10 mg prednisone (versus placebo) to an MTX-based tight control treatment strategy resulted in lower disease activity...

A tight control treatment strategy aiming for remission in early rheumatoid arthritis is more effective than usual care treatment in daily clinical practice: a study of two cohorts in the Dutch Rheumatoid Arthritis Monitoring registry

There is strong evidence from clinical trials that a ‘treat to target’ strategy is effective in reaching remission in rheumatoid arthritis (RA). However, the question is whether these results can...

Thematic stream: inflammatory arthritis: OP1. Long-Term Remission in Daily Clinical Practice: Excellent 2 Year Results with Treatment to Target in Very Early Rheumatoid Arthritis, Results of the Dream Remission Induction Cohort

Background: Remission is the primary therapeutic goal in rheumatoid arthritis (RA). Clinical trials have proven that systematic monitoring of disease activity, adjusting medication accordingly and aiming at a predefined target is effective in reaching this goal. However, aiming for remission is not implemented yet. Data on achieving and sustaining remission in daily clinical practice are limited. The objective was to evaluate disease activity in very early RA patients in clinical practice after 2 years of applying a tight control treatment strategy. Methods: Since January 2006, more than 700 newly diagnosed patients with early RA (symptom duration ≤1 year) were enrolled in the DREAM remission induction cohort. Treatment adjustments (4-8 weekly) were based on the DAS28, aiming at DAS28<2.6 (initial MTX, addition of SSZ, exchange of SSZ by anti-TNF in case of persistent high disease activity). Primary outcome was the disease activity according to DAS28, EULAR response criteria and modified ACR criteria for remission after 1 and 2 years. Additional measures included sustainability of remission. Results: Baseline characteristics were as follows: mean (SD) age 57.7 (13.9) years, 62.8% female, 56.6% RF positive, 62.4% anti-CCP positive, median symptom duration 15 weeks, mean (SD) baseline DAS28 5.0 (1.1) and 82.8% of patients fulfilled the ACR classification criteria for RA. Table 1 presents the clinical outcomes after 1 year (n = 392) and 2 years (n = 210) of follow-up. In 60% of patients sustained DAS28 remission (≥6 months) was observed during the first 2 years of follow-up. The majority of patients achieved remission on conventional DMARDs. Conclusions: Long-term remission is a realistic goal in very early RA patients in clinical practice. Implementation of a tight control treatment strategy results in high remission rates. The management of very early RA patients in clinical care can go beyond the control of signs and symptoms, and should aim at remission. Disclosure statement: M.V. received an unrestricted educational grant from Abbott, The Netherlands. All other authors declared no conflicts of interest.

Are switches from oral to subcutaneous methotrexate or addition of ciclosporin to methotrexate useful steps in a tight control treatment strategy for rheumatoid arthritis? A post hoc analysis of the CAMERA study

ObjectiveTo investigate the effects of a switch from oral methotrexate (MTX) to subcutaneous MTX (scMTX) or adding ciclosporin to oral MTX with a simultaneous reduction of the MTX dose, in...

Intensive management reduced disease activity in rheumatoid arthritis

Source Citation Grigor C, Capell H, Stirling A, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lance...

Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial

Present treatment strategies for rheumatoid arthritis include use of disease-modifying antirheumatic drugs, but a minority of patients achieve a good response. We aimed to test the hypothesis that an improved outcome can be achieved by employing a strategy of intensive outpatient management of patients with rheumatoid arthritis--for sustained, tight control of disease activity--compared with routine outpatient care. We designed a single-blind, randomised controlled trial in two teaching hospitals. We screened 183 patients for inclusion. 111 were randomly allocated either intensive management or routine care. Primary outcome measures were mean fall in disease activity score and proportion of patients with a good response (defined as a disease activity score <2.4 and a fall in this score from baseline by >1.2). Analysis was by intention-to-treat. One patient withdrew after randomisation and seven dropped out during the study. Mean fall in disease activity score was greater in the intensive group than in the routine group (-3.5 vs -1.9, difference 1.6 [95% CI 1.1-2.1], p<0.0001). Compared with routine care, patients treated intensively were more likely to have a good response (definition, 45/55 [82%] vs 24/55 [44%], odds ratio 5.8 [95% CI 2.4-13.9], p<0.0001) or be in remission (disease activity score <1.6; 36/55 [65%] vs 9/55 [16%], 9.7 [3.9-23.9], p<0.0001). Three patients assigned routine care and one allocated intensive management died during the study; none was judged attributable to treatment. A strategy of intensive outpatient management of rheumatoid arthritis substantially improves disease activity, radiographic disease progression, physical function, and quality of life at no additional cost.