Yan Geng1, Liujun Wang1, Xiaohui Zhang1, Lanlan Ji1, Xuerong Deng1, Zhuoli Zhang2. 1. Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China. 2. Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China. zhuoli.zhang@126.com.
Abstract
INTRODUCTION: Treat-to-target (T2T) strategy has greatly improved the prognosis of rheumatoid arthritis (RA). However, the additional benefit of targeting ultrasound (US) remission in addition to clinical remission has been debated. METHODS: RA patients in clinical remission or low disease activity were enrolled. They were assorted into two groups according to the principle of T2T strategy adopted. In clinical group, treatment decision was made with the aim of maintaining DAS28(ESR) ≤ 3.2 only, while in clinical US group, the aim was to attain total power Doppler (PD) US score = 0 in addition to DAS28(ESR) ≤ 3.2. The time-averaged DAS28, flare, and changes of treatment strategy were compared. RESULTS: One hundred ninety-four patients completed 1-year follow-up, with 100 in clinical US and 94 in clinical group. Compared to clinical group, time-averaged DAS28 in clinical US group was significantly lower (1.89 ± 0.51 vs. 2.33 ± 0.71, P < 0.01) with less flare (20.0% vs. 36.2%, P < 0.05). Furthermore, at the end of 1 year, significantly more patients successfully achieved step-down therapy (66.0% vs. 44.7%, P < 0.01) and dramatically fewer patients with step-up therapy in the clinical US group (13.0% vs. 25.5%, P < 0.05) compared to clinical group. In clinical US group, baseline DAS28(ESR) > 2.29, presence of subclinical synovitis, and step-down strategy were independent risk factors for relapse after clinical remission or low disease activity was achieved. CONCLUSIONS: An US-driven T2T in addition to current clinical remission strategy is associated with better control of the disease activity, reduction of relapse, as well as long-term step-down therapy. Step-down strategy should be carefully applied to the patients with baseline DAS28(ESR) over 2.29 and presence of subclinical synovitis even after they have achieved clinical remission or low disease activity. Key Points • Targeting ultrasound remission in addition to current T2T strategy is associated with a better control of RA. • Step-down strategy should be cautiously considered in those with DAS28(ESR) > 2.29 and baseline subclinical synovitis after they have achieved clinical remission or low disease activity.
INTRODUCTION: Treat-to-target (T2T) strategy has greatly improved the prognosis of rheumatoid arthritis (RA). However, the additional benefit of targeting ultrasound (US) remission in addition to clinical remission has been debated. METHODS:RApatients in clinical remission or low disease activity were enrolled. They were assorted into two groups according to the principle of T2T strategy adopted. In clinical group, treatment decision was made with the aim of maintaining DAS28(ESR) ≤ 3.2 only, while in clinical US group, the aim was to attain total power Doppler (PD) US score = 0 in addition to DAS28(ESR) ≤ 3.2. The time-averaged DAS28, flare, and changes of treatment strategy were compared. RESULTS: One hundred ninety-four patients completed 1-year follow-up, with 100 in clinical US and 94 in clinical group. Compared to clinical group, time-averaged DAS28 in clinical US group was significantly lower (1.89 ± 0.51 vs. 2.33 ± 0.71, P < 0.01) with less flare (20.0% vs. 36.2%, P < 0.05). Furthermore, at the end of 1 year, significantly more patients successfully achieved step-down therapy (66.0% vs. 44.7%, P < 0.01) and dramatically fewer patients with step-up therapy in the clinical US group (13.0% vs. 25.5%, P < 0.05) compared to clinical group. In clinical US group, baseline DAS28(ESR) > 2.29, presence of subclinical synovitis, and step-down strategy were independent risk factors for relapse after clinical remission or low disease activity was achieved. CONCLUSIONS: An US-driven T2T in addition to current clinical remission strategy is associated with better control of the disease activity, reduction of relapse, as well as long-term step-down therapy. Step-down strategy should be carefully applied to the patients with baseline DAS28(ESR) over 2.29 and presence of subclinical synovitis even after they have achieved clinical remission or low disease activity. Key Points • Targeting ultrasound remission in addition to current T2T strategy is associated with a better control of RA. • Step-down strategy should be cautiously considered in those with DAS28(ESR) > 2.29 and baseline subclinical synovitis after they have achieved clinical remission or low disease activity.
Authors: Siri Lillegraven; Femke H M Prince; Nancy A Shadick; Vivian P Bykerk; Bing Lu; Michelle L Frits; Christine K Iannaccone; Tore K Kvien; Espen A Haavardsholm; Michael E Weinblatt; Daniel H Solomon Journal: Ann Rheum Dis Date: 2011-10-12 Impact factor: 19.103
Authors: Josef S Smolen; Robert Landewé; Ferdinand C Breedveld; Maya Buch; Gerd Burmester; Maxime Dougados; Paul Emery; Cécile Gaujoux-Viala; Laure Gossec; Jackie Nam; Sofia Ramiro; Kevin Winthrop; Maarten de Wit; Daniel Aletaha; Neil Betteridge; Johannes W J Bijlsma; Maarten Boers; Frank Buttgereit; Bernard Combe; Maurizio Cutolo; Nemanja Damjanov; Johanna M W Hazes; Marios Kouloumas; Tore K Kvien; Xavier Mariette; Karel Pavelka; Piet L C M van Riel; Andrea Rubbert-Roth; Marieke Scholte-Voshaar; David L Scott; Tuulikki Sokka-Isler; John B Wong; Désirée van der Heijde Journal: Ann Rheum Dis Date: 2013-10-25 Impact factor: 19.103