Background
Currently it is recommended to optimize doses of biologics in RA patients who have maintained the therapeutic goal of remission for at least 6 months (1). Questions remain about the potential impact of these strategies on structural damage (2–4). Studies show that patients in clinical remission have synovitis detected by sensitive imaging studies such as magnetic resonance imaging (MRI) (5).
Objectives
The aim of this pilot study was to determine the percentage of patients who did not appear or increase the degree of synovitis evaluated by MRI after drug dose reduction at 6 months.
Methods
Observational, longitudinal, prospective study, which included patients with rheumatoide arthritis who are being treated with biologics and are in a state of clinical remission, defined as DAS28<2.6, for at least 6 months. Sociodemographic and disease variables were recorded at baseline. Determination by low-field MRI of sinovitis degree, lab determinations and variables associated with activity were assessed at baseline, 3 and 6 months. Patients who needed to increase dose by activity assessed by the clinician, before the next test image, they were retired of the protocol. A end visit were performed to them with laboratory and MRI. Dominant hand MRI was performed from distal radioulnar joint to MCPs, with the strings: GRAD ECO-3D coronal, STIR, coronal, axial-ECOT1 SPIN without gadolinium and SPIN ECOT1 with gadolinium. Images were performed and reported by a rheumatologist with experience in imaging reading and acquisition in patients with RA. Statistical analysis was performed using STATA statistical software.
Results
A total of 16 patients were included. Of these, 10 (62.5%) received etanercept, 2 tocilizumab (12.50%) and 4 adalimumab (25%). The mean disease duration before starting biological therapy was 4.5 years (1-17). The mean DAS28 at starting biological therapy was 5.3 (3,6-9). All patients with etanercept increased range of 7 to 10 days, except one patient dose reduced to 25 mg every 7 days. In 68% of patients no increase in the degree of synovitis was found. The disease activity and imaging data are shown in Table 1. No statistically significant differences in the disease activity before and after reduction (p 0.1) were found. However, differences between basal RAMRIS synovitis, at 3 months and at 6 months (p 0.019) were found.
Table 1
Baseline
3 months
6 months
DAS28, mean (IC)
2,24 (0,81–2,71)
2,24 (1,33–3)
2,36 (0,91–4,05)
Sinovitis, mean (IC)
1 (0–6)
1 (0–5)
1 (0–4)
RAMRIS, mean (IC)
17 (1–75)
17 (1–74)
19 (1–73)
Conclusions
In selected RA patients who are in permanent clinical remission, dose optimization may be an effective strategy that does not involve an increase in clinical activity, however, implications on structural outcome must be evaluated.
References
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