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Targeting remission beyond low disease activity may not produce worthwhile functional gains.
For patients who have rheumatoid arthritis or undifferentiated arthritis with a low Disease Activity Score (DAS), increasing treatment intensity to achieve remission may be unwarranted.
Although Health Assessment Questionnaire (HAQ) scores improve with higher treatment intensity in early rheumatoid arthritis and undifferentiated arthritis, no meaningful gains are made in functional ability.
Functional ability may be a more appropriate treatment goal than low DAS and HAQ scores.
Advances in pharmacologic treatment of patients with rheumatoid arthritis over the last decade have led to a less severe disease course and improved functional ability. Rheumatoid arthritis guidelines target low DAS and remission as the goals of therapy.
Sytske Bergstra and colleagues in the Netherlands pointed out that although intensifying drug therapy in patients with rheumatoid arthritis who are already in low disease activity may seem appropriate to prevent joint destruction and to improve function, it has never been proven.
The authors sought to determine whether seeking remission in low disease activity states by intensifying therapy is an appropriate goal. They presented their findings in a recent Arthritis Research & Therapy article.
The authors conducted an observational study using data collected in the IMPROVED study, a multicenter, single-blind, randomized clinical trial that looked at new-onset rheumatoid arthritis and undifferentiated arthritis.
Patients in the study were treated to a target of DAS indicative of remission.
• During the study period, DAS and HAQ scores showed statistically significant improvement (mean [standard deviation (SD)] baseline HAQ, 1.2 [0.7]; ÎHAQ, −0.59; 95% confidence interval [CI], −0.61 to −0.57; mean [SD] baseline DAS, 3.2 [0.9]; ÎDAS, −1.77; 95% CI, −1.79 to −1.75).
• In 69% of subjects, the change in HAQ score was significant.
• Mean changes in DAS in patients with low disease activity who did and did not receive treatment intensification were −0.48 and −0.15, respectively.
• Remission rates in patients with low disease activity who did and did not receive treatment intensification were 59% and 38%, respectively.
• A small but significant increase in HAQ scores was found.
Implications for physicians
• Intensification of pharmacologic treatment for patients with early rheumatoid arthritis or undifferentiated arthritis who have low DAS does not lead to further improvement in functional ability.
• Improvements in HAQ scores after treatment intensification in early rheumatoid arthritis and undifferentiated arthritis do not correlate with functional improvement.
• Targeting remission beyond low disease activity through intensification of therapy may not produce worthwhile functional gains.
AbbVie provided financial support for this study.
Bergstra SA, Olivas O, Akdemir G, et al. “Further Treatment Intensification in Undifferentiated and Rheumatoid Arthritis Patients Already in Low Disease Activity has Limited Benefit towards Physical Functioning.” Arthritis Res Ther. 2017 Sep 30;19(1):220. doi: 10.1186/s13075-017-1425-7.