Does Combined Clinical and Ultrasound Assessment Allow Selection of Individuals With Rheumatoid Arthritis for Sustained Reduction of Anti–Tumor Necrosis Factor Therapy?

Abstract

Objective. To investigate whether a strategy combining clinical and ultrasound (US) assessment can select individuals with rheumatoid arthritis (RA) for sustained dose reduction of anti-tumor necrosis factor (anti-TNF) therapies. Methods. As part of a real-world approach, patients with RA receiving anti-TNF therapies were reviewed in a dedicated biologic therapy clinic. Patients not taking oral corticosteroids with both Disease Activity Score in 28 joints (DAS28) remission (£2.6) and absent synovitis on power Doppler US (PDUS 0) for >6 months were invited to reduce their anti-TNF therapy dose by one-third. Results. Between January 2012 and February 2014, a total of 70 patients underwent anti-TNF dose reduction. Combined DAS28 and PDUS remission was maintained by 96% of patients at 3 months followup, 63% at 6 months, 37% at 9 months, and 34% at 18 months followup. However, 88% of patients maintained at least low disease activity (LDA) with DAS28 <3.2 and PDUS £1 at 6 months. The addition of PDUS identified 8 patients (25% of those that flared) in DAS28 remission, with subclinically active disease. Those who maintained dose reduction were more likely to be rheumatoid factor (RF) negative (46% versus 17%; P 5 0.03) and have lower DAS28 scores at biologic therapy initiation (5.58 versus 5.96; P 5 0.038). Conclusion. Combined clinical and US assessment identifies individuals in remission who may be suitable for anti-TNF dose reduction and enhances safe monitoring for subclinical disease flares. Despite longstanding severe RA, a subset of our cohort sustained prolonged DAS28 and PDUS remission. LDA at biologic therapy initiation and RF status appeared predictive of sustained remission.

Are there dangers in biologic dose reduction strategies?

“…There was no statistical difference in the proportion of patients with radiological structural damage progression between the M-and S-arms by the smallest detectable difference [13]. In a real world study, after an increase in their biological therapy dose following a flare, 85% of patients had disease activity of DAS28 b 2.6 or LDA (DAS 28 ≥ 2.6 to b 3.2) after an average 15 months of follow-up [14].…”

“…In Southampton a dose reduction strategy of 30% dose reduction was tried for RA patients on TNF inhibitors with "deep remission" having been on anti-TNF for N 1 year with no concomitant corticosteroid use [14]. "Deep remission" was defined as having no evidence of hand or wrist synovitis on power Doppler ultrasound, not being on corticosteroids and DAS 28 b 2.6 (for at least 6 months at entry).…”

Joint Ultrasonography in Rheumatoid Arthritis: Pathogenetic Rationale, Possible Use in Diagnosis, Therapy Efficiency Evaluation, and Outcome Prediction

“…[58] ремиссия по DAS28 и по ЭД через 3 мес сохранялась у 96%, через 6 мес -у 63%, через 9 мес -у 37%, через 18 мес -у 34% больных. У 88% пациентов через 6 мес DAS28 оставался <3,2 и ЭД ≤1.…”

Association Between Clinical Manifestations and Ultrasonic Signs of Inflammation in Patients With Rheumatoid Arthritis

“…Установле-но, что у пациентов с РА клиническая ремиссия по стан-дартизованным клинико-лабораторным индексам не все-гда соответствует критериям ультразвуковой ремиссии и у многих больных отмечаются признаки субклинического синовита [7]. В другом исследовании выявлено наличие ва-скуляризации синовиальной оболочки суставов, несмотря на клиническую ремиссию по DAS28 [8]. По данным ряда авторов, отмечена связь между «субклиническим» синови-том, выявляемым с использованием УЗИ, и прогрессиро-ванием деструкции суставов [9,10].…”