medwireNews: Sustained remission and low disease activity (LDA) remain uncommon in patients with rheumatoid arthritis (RA) receiving anti-tumor necrosis factor (TNF) therapy but can be predicted by several factors, shows an analysis published in Rheumatology.
Using data on 14,436 individuals from the British Society for Rheumatology Biologics Registry for Rheumatoid Arthritis who started their first TNF inhibitor between 2001 and 2013, Philip Hamann (University of Bristol, UK) and colleagues found that 2144 (14.9%) patients achieved one or more periods of sustained remission, while 3802 (26.3%) experienced sustained LDA.
Sustained remission was defined as DAS28-ESR of less than 2.6 points on two sequential follow-up visits during the first 3 years of follow-up, and sustained LDA was defined as DAS28-ESR of 2.6 to less than 3.2 points over the same timeframe.
Although sustained remission/LDA is described by the researchers as “infrequent,” they note that outcomes have improved over time, with the proportion of patients achieving these outcomes significantly increasing by 7.3% and 6.6%, respectively, between 2001–2010 and 2010–2013. This suggests that “clinicians and patients are increasingly successful in targeting remission,” say Hamann and team.
The study also identified changing demographics among those starting anti-TNF therapy in the 2001–2010 and 2010–2013 cohorts, with the mean swollen joint count decreasing from 11.4 to 8.7 and the tender joint count decreasing from 15.6 to 14.6. Significant decreases between the two periods were also seen in the erythrocyte sedimentation rate (ESR) and disease duration prior to starting TNF inhibitors (from a mean of 13.0 to 9.6 years). In addition, there was a significant increase in baseline methotrexate use over time, from 55.9% to 63.9% of patients, and baseline functional status (measured using the Health Assessment Questionnaire).
These data on changing demographics, together with the increased rates of sustained remission/LDA, “suggest changes in practice over the past decade are translating into improved outcomes,” say Hamann and colleagues.
Several significant predictors of sustained remission were identified in a multivariable analysis, with adalimumab (vs etanercept) use, baseline methotrexate use, a higher patient global assessment (PGA) score, and ex-smoking (vs current smoking) all significantly associated with an increased likelihood of sustained remission in the overall cohort. Conversely, female sex, older age at the start of anti-TNF therapy, infliximab use (vs etanercept), higher baseline ESR, increasing BMI, and poor baseline functional status were all negatively associated with the probability of sustained remission.
Sustained LDA was predicted by baseline methotrexate use, a higher swollen joint count, more recent initiation of anti-TNF therapy, ex-smoker status, and adalimumab use; while poorer functional status, higher ESR, greater body mass index, infliximab use, female sex, and older age at the start of anti-TNF therapy were associated with a reduced probability of sustained LDA.
“These results challenge assumptions about the treatment of RA patients with anti-TNF and show that patients treated in clinical practice today and the associations with sustained remission and LDA are significantly different from when anti-TNF first became available,” say the researchers.
They conclude: “Additional work is required to examine if predictors identified in this study are generic to all biologic-class drugs or if nuances are observed between different biologic classes that could help tailor treatment to individual patients.”
By Catherine Booth
medwireNews is an independent medical news service provided by Springer Healthcare. © 2019 Springer Healthcare part of the Springer Nature group
Rheumatology 2019; doi:10.1093/rheumatology/kez188
See also: