Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.


Eight Year Results of Disease Activity Steered Treatment in a Large Recent Rheumatoid Arthritis Cohort: Clinical and Radiological Outcomes.

Dirven1,  Linda, van den Broek1,  M., Klarenbeek1,  N.B., Han2,  K.H., Ronday3,  H.K, Kerstens4,  P.J.S.M., Huizinga1,  Tom W.J.

Leiden University Medical Center, Leiden, Netherlands
Maasstad Hospital, Rotterdam, Netherlands
Haga Hospital, The Hague, Netherlands
Jan van Breemen Research Institute | Reade, Amsterdam, Netherlands
VU University medical center, Amsterdam, Netherlands

Background/Purpose:

To compare 8-year clinical and radiological outcomes of four dynamic DAS steered treatment strategies (BeSt study) in recent onset rheumatoid arthritis (RA) patients.

Methods:

508 patients with recent onset RA were randomized to four treatment strategies: 1. sequential monotherapy, 2. step up combination therapy, 3. initial combination with prednisone, 4. initial combination with infliximab. Every three months, treatment adjustments were made based on DAS measurements (DAS >2.4: next treatment step; 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 1, 2, 3, 4, 5, 6, 7 and 8 and scored by two independent readers (LD and MvdB), blinded for patient identity and in random order.

Results:

After 8-years follow-up, 161 patients (32%) dropped out the study. Seventy-nine percent of the completers had a DAS <=2.4 and 52% DAS <1.6 (remission), equally distributed among the four groups (Table). Eighteen, 19, 17 and 15% of the patients in groups 1–4 were in drug free remission with a median (mean) duration of 45 (39) months. Six patients lost and twelve new patients achieved drug free remission in year 8, while eight 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 8 years time in all groups. Over time (LMM), patients in group 4 have significantly better functional ability compared to group 2 (mean HAQ: 0.57 and 0.71). After initial differences in years 1 and 2 between the 4 groups, yearly radiological damage progression rates were low and similar between all groups, reflecting the efficacy of DAS-steered therapy. Differences in total damage after 8 years are no longer statistically significant. Mean SHS progression in patients in sustained drug free remission was 0.1 (median (IQR) 0 (0–0.03)) per person year drug-free. Toxicity was comparable between the groups.

Table. 8-year results of the BeSt study.

 Group 1 n=126Group 2 n=121Group 3 n=133Group 4 n=128p-value
DAS <=2.4, (%)797684760.49
DAS <1.6, (%)495657470.48
DAS <1.6 drug free, %181917150.90
Still on initial treatment step, %29224566<0.001
Mean HAQ during 8 years0.690.710.630.57<0.05*
IFX current use, (%)211013240.06
Lost to follow-up, n (%)41 (33)43 (36)47 (35)30 (23)0.13
Missing data, no.81294 
SHS progression, median (mean)     
Total, year 0–83.0 (14.6)4.3 (13.9)2.0 (8.5)2.0 (8.3)0.567
year 10.3 (4.9)0.5 (2.3)0 (1.1)0 (1.0)0.005
year 20 (2.6)0 (1.1)0 (0.8)0 (0.6)0.028
year 30 (1.2)0 (1.5)0 (1.1)0 (0.6)0.841
year 40 (1.1)0 (1.3)0 (1.1)0 (0.8)0.898
year 50 (1.3)0 (1.6)0 (1.3)0 (1.2)0.593
year 60 (1.5)0 (1.2)0 (1.4)0 (0.9)0.841
year 70 (0.6)0 (1.7)0 (1.6)0 (0.7)0.066
year 80 (0.4)0 (1.0)0 (1.3)0 (0.7)0.527
†completers analysis,‡intention to treat.*LMM: group 2 vs 4, p < 0.05, group 1 vs 4, p= 0.055, all other, p > 0.05.

Conclusion:

After a clinically relevant earlier functional improvement with initial combination therapy than with initial monotherapy, improvement was maintained in all groups without deterioration over time with continued DAS steered treatment aiming at DAS <= 2.4. In addition, radiological damage was very low, even after 8 years. The percentages of patients in clinical remission and in drug free remission were stabilized.

To cite this abstract, please use the following information:
Dirven, Linda, van den Broek, M., Klarenbeek, N.B., Han, K.H., Ronday, H.K, Kerstens, P.J.S.M., et al; Eight Year Results of Disease Activity Steered Treatment in a Large Recent Rheumatoid Arthritis Cohort: Clinical and Radiological Outcomes. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2200
DOI:

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