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When it comes to what treatment and what target to use in RA, it just doesn't matter, provided you have a target in mind: treat to a target but neither the precise treatment nor the target matter! So if you have a favorite target in RA management in clinical practice, keep it as nobody agrees on the best one. And if your head doesn't hurt yet, it may as the data are all over the map for the favorite outcome measure to follow. It also depends on the patients enrolled and what you are trying to predict (e.g. less X-ray progression, sustained remission, ability to work, etc).
Bergstra SA, et al (#OP0252) reported at EULAR that the choice of initial treatment in RA doesn't matter provided a low DAS score is maintained. The data are from the BeST trial, with patients followed for 10 years. Those who had early intense treatment (infliximab or Cobra-type DMARDs) were more likely to have continuously low DAS scores, but if in sustained remission (DAS28 <2.4) then it didn't matter what treatment was used.
Similarly, Smolen J, et al (#THU0110) studied sustained remission in RA from the OPTIMA and PREMIER trials with adalimumab. Patients in sustained remission did better on all outcomes (HAQ and X-ray changes) irrespective of using CDAI, or DAS28 <2.6 as the outcome measure.
The findings were also true for function as measured by the HAQ. Carvalho PD, et al (#FRI0126) found that as long as remission is the target, any index will work.
Keystone E, et al (#THU0089) analyzed patients from the AMPLE trial (active RA ≤5years disease duration, MTX inadequate responders randomized to adding SC abatacept or adalimumab). They reported that CDAI and SDAI didn't do as well as the DAS28-CRP or M-DAS28 in terms of X-ray progression.
In a Japanese study of 15,000 patients with RA followed in clinical practice (Yokogawa N, et al #FRI0119), the sensitivity and specificity of the SDAI, CDAI, RAPID3 and an OMERACT modifcation of the DAS28 performed better than the DAS28. In a different cohort (METEOR with 33,000 RA patients), SDAI was the best predictor of low HAQ (Carvalho PD, #FRI0126).
Finally, in the CATCH (Canadian early inflammatory arthritis cohort) it was shown that there are differences between thresholds for the DAS28 if CRP was used compared to ESR (Kuriya B, et al, Clin Exp Rheuamtol 2017 March 23).
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About the Author
Dr. Janet Pope
Dr. Janet Pope is Professor of Medicine at Western University and Division Head of Rheumatology. Dr. Pope's research interests include epidemiologic studies in scleroderma, classification criteria in systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis.
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