Inflammation and biologic therapy in patients with rheumatoid arthritis achieving versus not achieving ACR/EULAR Boolean remission in a treat-to-target study

Abstract

ObjectiveTo investigate limiting factors of American College of Rheumatology (ACR)/EULAR Boolean remission in rheumatoid arthritis (RA), and compare patients who fulfil the criteria to patients who only partly fulfil the criteria, with respect to imaging inflammation and biologic disease modifying anti-rheumatic drug (DMARD) usage.MethodsPatients with DMARD-naïve RA were treated according to current recommendations in the the ARCTIC trial (Aiming for Remission in rheumatoid arthritis: a randomised trial examining the benefit of ultrasound in a Clinical TIght Control regimen). Limiting factors of reaching ACR/EULAR Boolean remission at 2 years were assessed. Imaging inflammation (ultrasound and MRI) in patients in remission was compared with patients failing to fulfil different components of the criteria. The OR of biologic therapy was calculated using logistic regression.ResultsOf 203 patients, 112 (55%) reached ACR/EULAR Boolean remission; 49 (24%) fulfilled three of four criteria. The main limiting factors were patient global assessment (PGA) (59%) and tender joints (22%). Imaging inflammation was not significantly different for patients in remission and patients not fulfilling the criteria due to elevated PGA and/or tender joints, but higher odds of using biologics (OR 3.63, 95% CI 1.73 to 7.61) were observed.ConclusionsPGA and tender joints were the factors most often limiting achievement of ACR/EULAR Boolean remission. The level of imaging inflammation was not elevated in these patients compared with patients in remission, but the odds of using biologic DMARDs were higher.

Overtreatment in rheumatoid arthritis: are there reasons for concern?

“…These clues of overtreatment are especially important given the absence of objective clinical and imaging signs of inflammation. 1 The low scores observed with MRI (~4) are compatible with prior observations in normal people without arthritis 16 and in patients with RA in remission. 17 18 However, the ARCTIC trial 2 providing the original data is not aligned with current clinical practice.…”

“…There are ample reasons to consider the exclusion of PGA from the definitions of remission and low disease activity, especially if they are meant to drive the use of immunosuppressive medication. The supporting evidence is reinforced by many of the results reported by Paulshus Sundlisæter et al 1 …”

“…Recent systematic reviews determined a 19% prevalence of PGA-near-remission in RA for both clinical trials 7 and cohorts, 8 representing 45% and 60%, respectively, of all patients otherwise in remission. This percentage was of 21% in the study of Paulshus Sundlisæter et al 1 …”

“…The authors compared patients in American College of Rheumatology/ European Alliance of Associations for Rheumatology (ACR/EULAR) Boolean remission and in ‘near-remission’ regarding the use of biological disease-modifying antirheumatic drugs (bDMARDs), the incidence of adverse effects and the presence of subclinical inflammation. 1 This is an ancillary analysis of data from the ARCTIC trial, which tested the systematic use of ultrasound in the follow-up of patients with early RA treated in a tight control regimen. 2 The remission status was defined at the 2 years time point.…”

“…The conclusion that PGA-near-remission is not associated with subclinical inflammation is supported, in this study, by ultrasound evaluation of 32 joints and MRI of the dominant hand. 1 Of note, 12 joints in the feet, not included in clinical 28-joint counts, were included in the ultrasound evaluation. This imaging data does not support the interpretation that the slightly higher levels of CRP and physician global assessment observed in the PGA-near-remission group (at 2 years follow-up) might reflect the presence of subclinical inflammation.…”