Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Seven Year Results of DAS Steered Treatment in the BeSt Study: Clinical and Radiological Outcomes.

Dirven5,  L., van den Broek5,  M., Klarenbeek5,  N. B., van Krugten1,  M. V., van der Lubbe2,  P. A. H. M., Kerstens3,  P. J. S. M., Huizinga5,  T. W. J.

Admiraal de Ruyter Hospital
Haga Hospital
Jan van Breemen Institute
Leiden Univ Med Ctr, Leiden, The Netherlands
Leiden University Medical Center
VU Medical Centre, Amsterdam, The Netherlands

Objective:

To compare clinical and radiological outcomes of four treatment strategies after 7 years DAS-steered treatment in recent onset rheumatoid arthritis.

Methods:

508 recent onset RA patients were randomized into four treatment strategies: 1. sequential monotherapy, 2. step up combination therapy, 3. initial combination with prednisone, 4. initial combination with infliximab. Treatment adjustments were made every three months based on DAS measurements (if DAS >2.4: dose increase/switch next treatment step, if DAS <= 2.4 during >=6 months: taper to maintenance dose, next if DAS <1.6 during >=6 months: stop anti-rheumatic treatment). Functional ability (HAQ) was analyzed with a linear mixed model (LMM) with time, treatment and time*treatment as independent variables. Joint damage progression (Sharp-van der Heijde Score (SHS)) was assessed on X-rays of baseline and year 2, 4, 5, 6, 7 and scored by two independent readers in random order, blinded for patient identity.

Results:

After 7-years follow-up, 130 patients (26%) dropped out the study. At t=7 year, 79% had a DAS <=2.4 and 46% DAS <1.6 (remission), equally distributed among the four groups (table). Sixteen, 16, 17 and 17% of the patients in groups 1–4 were in drug free remission with a median (mean) duration of 36 (31) months. Ten patients lost and six new patients achieved drug free remission in year 7. Four patients with prolonged drug-free remission dropped out. The initial improvement of function, which occurred earlier in groups 3 and 4 than in groups 1 and 2, was maintained without deterioration over 7 years time in all groups. Over time (LMM), patients in group 4 have significantly better functional ability compared to groups 1 and 2 (mean HAQ: 0.70, 0.71 and 0.57 respectively). After initial differences between the 4 groups, yearly radiological damage progression rates were similar between all groups, reflecting the efficacy of DAS-steered therapy. Differences in total damage after 7 years are no longer statistically significant. Mean SHS progression in patients in sustained drug free remission was 0.3 (median (IQR) 0 (0–0.2)) per person year drug-free. Toxicity was comparable between the groups.

Conclusion:

With continued DAS steered treatment aiming at DAS <=2.4, functional improvement was maintained and radiological progression as well as percentages in remission and in drug free remission were stabilized. Over 7 years time, patients treated with initial combination therapy with infliximab had better functioning than patients treated with initial monotherapy.

Table. 7-year results of the BeSt study

 Group 1 n = 126Group 2 n = 121Group 3 n = 133Group 4 n = 128p-value
completersn = 83n = 72n = 79n = 97 
DAS <=2.4, (%)†827682760.64
DAS <1.6, (%)†493953450.35
DAS <1.6 drug free, %†161817170.96
Still on initial treatment step, %‡21162055<0.001
Mean HAQ during 7 years‡0.700.710.630.57<0.001*
IFX current use, (%)‡1461121<0.05
Drop outs, n (%)‡33 (26)40 (33)35 (26)22 (17)0.04
SHS progression, median (mean)†     
  Total, year 0–73.8 (15.1)3.5 (10.7)2.0 (8.4)2.0 (5.5)0.205
   year 0–21 (6.4)0.5 (3.2)0 (1.6)0.5 (1.7)0.002
   year 2–40 (2.6)0.3 (2.4)0 (2.1)0 (1.1)0.562
   year 50 (1.2)0 (1.5)0 (1.2)0 (1.1)0.822
   year 60 (1.7)0 (1)0 (0.9)0 (0.7)0.765
   year 70 (0.9)0.5 (1.4)0 (1.1)0 (0.2)0.077
*LMM: group 1 and 2 vs 4, p < 0.05.†completers analysis,‡intention to treat.

To cite this abstract, please use the following information:
Dirven, L., van den Broek, M., Klarenbeek, N. B., van Krugten, M. V., van der Lubbe, P. A. H. M., Kerstens, P. J. S. M., et al; Seven Year Results of DAS Steered Treatment in the BeSt Study: Clinical and Radiological Outcomes. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :334
DOI: 10.1002/art.28103

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