POS0207 UNRAVELING THE COMPLEX INTERACTION BETWEEN DISEASE ACTIVITY AND FATIGUE IN EARLY RA: A MEDIATION ANALYSIS WITH DATA FROM THE CareRA TRIAL

Background

Fatigue is recognized as one of the most important symptoms of rheumatoid arthritis (RA). Although inflammation is often proposed as the predominant pathophysiological mechanism, many patients with RA continue to experience fatigue despite inflammatory disease control. The relationship between RA disease activity and fatigue appears to be complex and is likely confounded by cognitive, emotional and social aspects.

Objectives

To unravel the complex interaction between disease activity and fatigue in early RA.

Methods

Data were analyzed from the 2-year treat-to-target trial Care in early RA (CareRA), which compared different remission-induction DMARD regimens, either with or without bridging glucocorticoids, in treatment-naïve patients with early RA. Fatigue was measured on a visual analog scale (VAS) at every study visit. The association between inflammatory disease activity (DAS28-CRP) and fatigue (VAS) over time was studied with a multilevel mediation analysis, including as mediators the individual components of the DAS28-CRP, pain (VAS), disability (HAQ), psychosocial aspects (Short-Form 36 [SF-36]), illness perceptions (Revised Illness Perception Questionnaire [IPQ-R]), and sleep quality (Pittsburgh Sleep Quality Index [PSQI]).

Results

A total of 356 patients were included in these analyses, with a mean (SD) fatigue (VAS) of 48/100 (24) at study initiation. Although there was a consistently positive association between DAS28-CRP and fatigue over time, this association was fully mediated by patient global assessment (PGA) and pain, and to a lesser extent by SF-36 Mental Health and the PSQI global score (Figure 1). Full mediation implies the absence of a significant direct association between DAS28-CRP and fatigue after adjusting for these mediators. In addition, no mediating effect was found for tender/swollen joint counts or CRP.

Figure 1.

Mediation analysis of the association between DAS28-CRP and fatigue (VAS) over time.

Reported are the standardized regression coefficients with indicators of significance (* p < 0.05; ** p < 0.01; *** p < 0.001). DAS28-CRP = Disease Activity Score in 28 joints with C-reactive protein, SJC28/TJC28 = swollen/tender joint count in 28 joints, HAQ = Health Assessment Questionnaire, SF-36 = Short-Form 36, MH = mental health, RE = emotional role functioning, SF = social functioning, IPQ-R = Revised Illness Perception Questionnaire, PSQI = Pittsburgh Sleep Quality Index

Conclusion

Our mediation analysis suggests that the relationship between disease activity and fatigue in early RA is complex and fully mediated by aspects of wellbeing like pain, mental health, sleep quality, and the patient’s overall assessment of disease. These results imply a mainly indirect relation between fatigue and inflammation. Clinicians should reserve specific attention for the psychosocial determinants of fatigue, particularly when no improvement is seen with DMARDs.

Disclosure of Interests

Michaël Doumen: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Diederik De Cock: None declared, Johan Joly: None declared, Rene Westhovens Speakers bureau: Honoraria for lectures:

- Celltrion

- Gilead

- Galapagos, Consultant of: - Celltrion

- Gilead

- Galapagos, Patrick Verschueren Speakers bureau: MSD

Galapagos

Eli Lilly, Consultant of: Sanofi

Galapagos

Pfizer

Gilead, Grant/research support from: Pfizer Chair Management of Early Rheumatoid Arthritis at KU Leuven Belgium

AB1395 PATIENTS’ AND RHEUMATOLOGISTS’ PERCEPTIONS REGARDING TAPERING OF RITUXIMAB

Background

Rituximab is an efficacious drug for the treatment of Rheumatoid Arthritis (RA). The commonly used dose consists of two infusions of 1000 mg with a 2-week interval, but evidence is growing that a lower dose could be as effective. Before implementing a tapering strategy, understanding the perceptions of patients and rheumatologists in this regard is important.

Objectives

The aim was to investigate patients’ and rheumatologists’ perceptions on rituximab tapering.

Methods

Patients with RA, who were currently or previously treated with rituximab, and rheumatologists were invited to participate in a qualitative study consisting of individual, in depth, face-to-face, semi-structured interviews. Participants were recruited based on purposive sampling to ensure diversity. Interviews were conducted via video or telephone call. Additional participants were interviewed until data saturation was achieved, meaning no new information emerged from the last 3 interviews. Interviews were audiotaped and transcribed verbatim, followed by analysis according to the Qualitative analysis guide of Leuven, which generated themes. Patient experts were involved in this research.

Results

In total, 16 patients with RA and 13 rheumatologists were interviewed. Four themes were found: In favour/reluctant of tapering, shared decision making, implementation and evidence gap (Figure 1). Patients and rheumatologists were IN FAVOUR of rituximab tapering, for reasons of safety and economic benefit. Patients and rheumatologists mentioned that a lower dose could allow shorter retreatment intervals, which might avoid flares. Furthermore, rheumatologists referred to available evidence of the effectiveness of a lower rituximab dose. Additionally, patients and rheumatologists indicated that the dose could be tailored based on the patient’s clinical manifestations, e.g. usual cycle interval and disease activity measures. However, some patients and rheumatologists felt RELUCTANT towards rituximab tapering. Patients and rheumatologists were concerned about potential loss of effectiveness and quality of life, next to more practical concerns. Rheumatologists mentioned that they had insufficient experience with rituximab in general to feel comfortable with tapering. Moreover, when applying an on-flare retreatment strategy, patients present with an active disease at the time of retreatment and therefore the option of tapering is less appealing. The next theme was SHARED DECISION MAKING. Patients and rheumatologists mentioned that patients have trust in their physician and thus leave the tapering decision in the hands of the rheumatologists. However, rheumatologists added that this should be combined with explanation of the tapering rationale. Another theme was IMPLEMENTATION. When asking participants about 2 possible dose reduction regimens, a cycle consisting of 2 infusions with a lower dose or a cycle of only 1 infusion with a higher dose, advantages were raised for both regimens (e.g. safety reasons and time savings, respectively). On the other hand, the on-flare retreatment regimen itself was already perceived as a kind of tapering, as the interval is prolonged as much as possible between the cycles. EVIDENCE GAP was the last theme, meaning that patients and rheumatologists felt there was a need of more research regarding rituximab tapering. For instance, predictive tools for flares, as well as the possibility of subcutaneous administration of rituximab, were mentioned as unmet needs by rheumatologists.

Figure 1.

Conceptual framework of the patients’ and rheumatologists’ perceptions regarding tapering of rituximab. (Icons: Iconfinder)

Conclusion

It seems that rituximab tapering is not yet incorporated in daily practice as much as tapering of other antirheumatic drugs and this could potentially be related to a lack of experience with rituximab. However, with appropriate education and communication, rheumatologists and patients are willing to taper rituximab. Although, many questions remain, indicating an evidence gap and a need of more research.

Disclosure of Interests

None declared

POS0157 IMPLEMENTATION OF A VACCINATION TOOL IN THE ELECTRONIC PATIENT HEALTH RECORD COINCIDES WITH A SIGNIFICANT INCREASE IN VACCINATION COVERAGE

Background

Patients with immune-mediated inflammatory diseases (IMID) are at higher risk for infectious diseases. Despite this increased risk and the available guidelines1,2, we reported a suboptimal vaccination rate of 27 % of IMID patients in 2018. In the meantime, a vaccination module was introduced in the electronic patient medical record (EMR) of our hospital to accurately document and monitor vaccination status of patients.

Objectives

To evaluate the impact of a new vaccination module in the patient health record on vaccination coverage in a previously included IMID cohort.

Methods

Between Aug and Oct 2021, the vaccination status of 1435 (out of the original 1488) IMID patients (45 % male, median age 53.6 years) was collected (790 patients with IBD (inflammatory bowel diseases), 607 with rheumatologic inflammatory conditions (RHEU)(RA or SpA), and 38 with dermatologic inflammatory conditions(DER)) and was compared to that of 2018. The vaccination status for influenza (FLU), pneumococci (Pnc), hepatitis B (Hep B) and tetanus (TT) was obtained mainly through the patients’ electronic medical records. Missing data were added after contacting patients or their general practitioner.

Results

From 2018 to 2021, the overall vaccination coverage (excluding TT) of all IMID patients significantly increased from 42 % to 66 % (p<0.001, Figure 1).

Figure 1.

Percentages of total vaccination coverage in 2018 vs. 2021 in patients with IMID – TT vaccination excluded

For patients with RHEU, the vaccination coverage significantly increased, namely from 69.0% to 75 % for FLU (p<0.001), from 36 % to 89 % for Pnc (p<0.001), from 57 % to 73 % for Hep B (p<0.001) and from 34 % to 74 % overall (p=0.008) (Figure 1 and Table 1).

Table 1.

Vaccine coverage in 2018 vs. 2021 in patients with IMID

FLU (%)Pnc (%)Hep B*(%)TT (%)IBD (n=790)2018: 762018: 732018: 672018: 802021: 872021: 822021: 792021: 67p-value < 0.001p-value < 0.001p-value < 0.001p-value < 0.001RHEU (n=607)2018: 692018: 362018: 572018: 652021: 752021: 892021: 732021: 41%p-value < 0.001p-value < 0.001p-value < 0.001p-value = 0.038DER (n=38)2018: 742018: 612018: 472018: 792021: 712021: 822021: 652021: 71p-value = 0.116p-value = 0.401p-value < 0.001p-value = 0.394All IMID (n=1435)2018: 732018: 582018: 632018: 742021: 812021: 852021: 772021: 56p-value < 0.001p-value < 0.001p-value < 0.001p-value < 0.001

*recommended in all seronegative IMID patients with IBD and patients at risk for other IMIDs

Similarly, the vaccination coverage in IBD patients increased significantly from 76 % to 87 % for FLU (p<0.001), from 73 % to 82 % for Pnc (p<0.001), from 67 % to 79 % for Hep B (p<0.001) and from 47 % to 61 % overall (p<0.001) (Figure 1 and Table 1).

For patients with DER, vaccination coverage significantly increased from 47 % to 65 % for Hep B (p<0.001) (Table 1). TT vaccination coverage decreased in all 3 IMID groups from 2018 to 2021.

Conclusion

The implementation of a vaccination tool integrated in the EMR coincided with a significant increase in vaccination rates and also in the total amount of IMID patients that were fully vaccinated according to guidelines. Quite likely, the suboptimal vaccination rate measured in 2018 and the COVID-19 pandemic also raised awareness among patients and healthcare professionals about the importance of following vaccination guidelines.

References

[1]Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020 Jan;79(1):39-52. doi: 10.1136/annrheumdis-2019-215882. Epub 2019 Aug 14. PMID: 31413005.

[2]Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis. 2014;8:443–468.

Disclosure of Interests

Johan Joly: None declared, Barbara Neerinckx Grant/research support from: pfizer, Kurt de Vlam Speakers bureau: Celgene Eli Lilly, Galapagos, Novartis, UCB, Consultant of: Celgene, Eli Lilly, Amgen, AbbVie, Galapagos, Novartis, UCB, Grant/research support from: Celgene and Galapagos, Liselotte Fierens: None declared, Els De Dycker: None declared, Tine Vanhoutvin: None declared, Petra De Haes Speakers bureau: Celgene, GSK, Novartis, Consultant of: Celgene, GSK, Novartis, Paul De Munter Grant/research support from: Sanofi-Pasteur, Joao Sabino Speakers bureau: Abbvie, Falk, Takeda, Janssen, Fresenius, Consultant of: Janssen, Ferring, Grant/research support from: Galapagos, Severine Vermeire Speakers bureau: AbbVie, Abivax, Agomab, Arena Pharmaceuticals, Avaxia, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Dr Falk Pharma, Ferring, Galapagos, Genentech-Roche, Gilead, GSK, Hospira, Janssen, Mundipharma, MSD, Pfizer, Prodigest, Progenity, Prometheus, Robarts Clinical Trials, Second Genome, Shire, Surrozen, Takeda, Theravance, Tillots Pharma AG, Consultant of: AbbVie, Abivax, Agomab, Arena Pharmaceuticals, Avaxia, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Dr Falk Pharma, Ferring, Galapagos, Genentech-Roche, Gilead, GSK, Hospira, Janssen, Mundipharma, MSD, Pfizer, Prodigest, Progenity, Prometheus, Robarts Clinical Trials, Second Genome, Shire, Surrozen, Takeda, Theravance, Tillots Pharma AG, Grant/research support from: AbbVie, J&J, Pfizer, Galapagos, Takeda, Marc Ferrante Speakers bureau: AbbVie, Amgen, Biogen, Boehringer Ingelheim, Falk, Ferring, Janssen, Lamepro, MSD, Mylan, Pfizer, Sandoz, Takeda, Truvion Healthcare, Consultant of: AbbVie, Boehringer Ingelheim, Celltrion, Janssen, Lilly, Medtronic, MSD, Pfizer, Sandoz, Takeda, Thermo Fisher, Grant/research support from: AbbVie, Amgen, Biogen, Janssen, Pfizer, Takeda, Viatris, Patrick Verschueren Speakers bureau: Eli Lilly, MSD, Galapagos, Roularta, Consultant of: Eli Lilly, Nordic Pharma, Galapagos, Gilead, Pfizer, ABBVIE, Celltrion, BMS, UCB, Pfizer, Sidekick Health, Grant/research support from: Pfizer

POS0523 FATIGUE TRAJECTORIES IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: A LONGITUDINAL ANALYSIS OF DATA FROM THE CareRA TRIAL

Background

Fatigue is a common and impactful symptom of rheumatoid arthritis (RA). Given its heterogeneity and unpredictable nature, studies on contributing factors of RA-related fatigue should include multidimensional measures of fatigue and assess these longitudinally with multivariate methods, starting early in the disease.

Objectives

We aimed to explore the longitudinal course of fatigue and its predictors among patients with early RA starting DMARD therapy.

Methods

Data came from the 2-year treat-to-target trial Care in early RA (CareRA) and its 3-year extension. Fatigue was measured based on visual analog scale (VAS), Multidimensional Fatigue Inventory (MFI), and Short-Form 36 (SF-36). Longitudinal fatigue trajectories were identified with multivariable growth mixture modeling. Baseline and early predictors of trajectory membership, including treatment response, were studied with multinomial logistic regression adjusted for age, gender, and treatment type. Patient global assessment (PGA), pain (VAS), and disability (HAQ) were studied in separate models because of collinearity (Spearman r > 0.60). For all models, posterior probabilities of trajectory assignment were included in the regression as weights to account for classification uncertainty. Treatment response was defined, based on whether remission (DAS28-CRP < 2.6) was achieved by week 16 and sustained until year 2, as either early persistent response, secondary failure, or delayed response.

Results

In total, 356 and 244 patients were included in the 2-year and 5-year analyses, respectively. Mean (SD) fatigue (VAS) at inclusion was 48/100 (24). Four fatigue trajectories were identified: Rapid, Gradual, and Transient Improvement, and Early Deterioration, consisting of 10%, 14%, 56%, and 20% of patients, respectively (Figure 1). Higher PGA, pain and HAQ at baseline were associated with increased probability of Rapid Improvement compared to Transient Improvement or Early Deterioration (Table 2). Secondary treatment failure and delayed treatment response strongly increased the probability of less positive fatigue trajectories when compared to early persistent response.

Figure 1.

Latent trajectories of fatigue evolution over the first 2 years in CareRA (n = 356).

Conclusion

The longitudinal course of fatigue in early RA is dynamic but highly refractory, with less than 25% of patients making lasting improvements and 20% even experiencing worsening fatigue despite intensive DMARD therapy. Remarkably, a higher perceived disease impact at baseline was associated with an increased probability of fatigue improvement, possibly reflecting the fluctuating nature of this complex symptom. However, early inflammatory disease control appears to be the most important contributor to improved long-term fatigue outcomes, illustrating the far-reaching impact of the therapeutic window of opportunity in early RA.

References

/

Table 1.

Predictors of fatigue trajectory membership

Gradual improvementTransient improvementEarly deteriorationOR (95% CI)pOR (95% CI)pOR (95% CI)pFatigue (0-100)1.01 (0.99; 1.04)0.320.99 (0.97; 1.01)0.160.98 (0.96; 1.00)0.07PGA (0-100)0.98 (0.95; 1.01)0.110.96 (0.94; 0.99)0.0030.95 (0.92; 0.98)<0.001Tender joints (0-28)1.00 (0.91; 1.13)0.821.00 (0.91; 1.09)0.970.99 (0.88; 1.11)0.80Swollen joints (0-28)1.01 (0.90; 1.15)0.820.99 (0.89; 1.10)0.830.93 (0.81; 1.06)0.30CRP (mg/dL)1.00 (0.98; 1.01)0.670.99 (0.98; 1.01)0.361.00 (0.97; 1.02)0.66Pain (0-100)0.99 (0.96; 1.02)0.360.96 (0.94; 0.98)0.0020.95 (0.92; 0.98)<0.001HAQ (0-3)1.07 (0.52; 2.20)0.850.55 (0.30; 1.01)0.050.24 (0.11; 0.51)<0.001SF-36 Mental Component Score (0-100)1.00 (0.96; 1.04)0.971.02 (0.99; 1.06)0.231.02 (0.98; 1.06)0.34Treatment responseSecondary failure2.22 (0.78; 6.32)0.133.87 (1.57; 9.55)0.0037.88 (2.68; 23.13)<0.001Delayed response2.93 (0.70; 12.15)0.146.82 (1.91; 24.44)0.00311.14 (2.33; 53.19)0.003

Disclosure of Interests

Michaël Doumen: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Diederik De Cock: None declared, Johan Joly: None declared, Rene Westhovens Speakers bureau: - Celltrion

- Galapagos

- Gilead, Consultant of: - Celltrion

- Galapagos

- Gilead, Patrick Verschueren Speakers bureau: - MSD

- Eli Lilly

- Galapagos, Consultant of: - Sanofi

- Galapagos

- Gilead

- Pfizer, Grant/research support from: Pfizer Chair Management of Early Rheumatoid Arthritis at KU Leuven Belgium

AB1394 ON-FLARE RETREATMENT WITH RITUXIMAB IN RHEUMATOID ARTHRITIS: PATIENTS’ AND RHEUMATOLOGISTS’ PERCEPTIONS

Background

Rituximab is an efficacious drug for the treatment of Rheumatoid Arthritis (RA). According to literature, administration of rituximab can be based on a fixed interval or on relapse of disease activity. In some countries, like Belgium, after the first rituximab cycle a flare is required for reimbursement of a subsequent cycle. A better understanding of the perceptions of patients and rheumatologists regarding this retreatment strategy would be informative in view of potential adjustments.

Objectives

The aim was to investigate patients’ and rheumatologists’ perceptions on the on-flare retreatment strategy of rituximab.

Methods

Patients with RA, who were currently or previously treated with rituximab, and rheumatologists were invited to participate in a qualitative study consisting of individual, in depth, face-to-face, semi-structured interviews. Participants were recruited based on purposive sampling to ensure diversity. Interviews were conducted via video or telephone call. Additional participants were interviewed until data saturation was achieved, meaning no new information emerged from the last 3 interviews. Interviews were audiotaped and transcribed verbatim, followed by analysis according to the Qualitative analysis guide of Leuven, which generated themes and subthemes. Patient experts were involved in this research.

Results

In total, 16 patients with RA and 13 rheumatologists were interviewed. Five overarching themes were generated from the interviews: flare definition, recognition, reaction, balance between benefits and barriers and suggestions (Figure 1). Patients and rheumatologists described how they perceive the on-flare retreatment strategy in daily practice, starting with the FLARE DEFINITION itself. Namely, what patients perceived as a flare and the impact of this flare. The second step was RECOGNITION of the flare. Both rheumatologists and patients indicated that patients are able to recognise a flare. However, the patient’s ability to discriminate between inflammatory and other types of pain was perceived as a difficulty. Moreover, patients indicated that depending on the flare’s intensity, they can cope with it themselves, delaying the need for a rituximab cycle. The next step after correctly recognising a flare, was the REACTION, from both the patient’s and rheumatologist’s side. It was stressed that patients must contact their treating rheumatologists in time. Furthermore, a swift response of the rheumatologists was perceived as important. After confirming eligibility, the shared decision to plan a new rituximab cycle can be made while keeping an eye on the organisation. Remarkably, it seemed that rheumatologists approached the retreatment strategy in different ways, meaning that not everyone adhered to the on-flare principle. Several perceived BENEFITS (e.g. lower safety risk, societal cost savings) and BARRIERS (e.g. disease activity fluctuations, slow working mechanism) were mentioned, making clear that the optimal retreatment strategy should be based on a BALANCE between both. Finally, some SUGGESTIONS (e.g. biomarkers for flare prediction, subcutaneous administration of rituximab) were brought up that could be helpful in applying the optimal retreatment strategy.

Figure 1.

Conceptual framework of the perceptions of patients and rheumatologists regarding the on-flare retreatment strategy with rituximab. SDM = Shared decision making. (Icons: Iconfinder)

Conclusion

Patients play an important role in the recognition of flares and their reaction, in shared decision with the rheumatologist, contributes to the effectiveness of the rituximab on-flare retreatment strategy. Rheumatologists handle the on-flare retreatment strategy as pragmatically as possible, resulting in different approaches. Moreover, both benefits and barriers of on-flare retreatment were perceived, making clear that a balance should be found to determine the optimal retreatment strategy.

Disclosure of Interests

None declared

OP0032 AN ECONOMIC WINDOW OF OPPORTUNITY FOR PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: 5-YEAR COST-EFFECTIVENESS ANALYSIS OF THE CareRA TRIAL

Background

The CareRA trial showed that remission induction with methotrexate (MTX) and glucocorticoid (GC) bridging in a treat-to-target setting is cost-effective up to 2 years in early Rheumatoid Arthritis (eRA) patients.

Objectives

To evaluate the long-term cost-effectiveness of treat-to-target treatments among recently diagnosed (<1 year), DMARD naïve patients with eRA using MTX and a step-down GC scheme (COBRA-Slim) compared to (a) the same combination with either sulphasalazine (COBRA-Classic) or leflunomide (COBRA-Avant-Garde) in high-risk patients and (b) MTX without GCs (Tight-Step-Up: TSU) in low-risk patients up to 5 years.

Methods

We used data from the 2-year RCT CareRA trial and its 3-year observational follow-up, CareRA plus. Patients completing the 2-year visit of CareRA were eligible for participation in CareRA plus, in which patients were evaluated every 6 months till year 5. Healthcare costs considered in this piggyback economic analysis were rheumatology visits, RA-related medication (synthetic and biological DMARDs, GCs, and all recorded analgesics including paracetamol, non-steroidals, tramadol and opioids), hospital admissions, laboratory tests and radiographs occurring during the 5-year trial. All pricing is based on December 2021 rates. Total costs per resource were calculated by multiplying the number of resources by the cost unit price extracted from Belgian national websites. Total costs per patient were obtained by summing costs of all resources. Effectiveness was measured with DAS28-CRP and compared between the originally allocated treatment arms. An incremental cost-effectiveness ratio (ICER) was calculated by dividing the cost difference by the DAS28-CRP<2.6 remission difference per pair of treatment schemes. Multiple imputation was used to handle missing data and non-parametric bootstrapping with 25000 iterations of random sampling with replacement to calculate confidence intervals (95% CIs).

Results

Of 322 eligible patients, 252 were included in CareRA plus, of which 203 completed the trial. Rates of disease control (DAS28-CRP<2.6) at year 5 in high-risk patients were 68%, 72% and 64% in the Classic, Slim and Avant-Garde group respectively (p=0.63) and related total costs were €11 358.39 (CI 7 776.84-14 939.93), €8 463.12 (CI 6 789.44-10 136.80), €11 752.47 (CI 7 705.11-15 799.82) respectively. In the low-risk population, 80% of patients in Slim and the TSU arm reached remission (DAS28-CRP<2.6) at year 5. While the costs were €6 332.55 (CI 3 607.63-9 057.48) for Slim, and €10 398.19 (CI 4165.95-16630.43) for TSU. In the high-risk group, Classic (ICER -€723.82) and Avant-Garde (ICER -€411.17) were more expensive and less effective compared to Slim. In the low-risk group, Slim was less expensive (Δ -€4 065.64) and equally effective as TSU. Figure 1 depicts how the different medication costs evolved during the 5-year follow-up. 22% of all patients were ever on bDMARDs. More specifically in 23% (16/69) of Classic, 21% (16/75) of Slim high-risk, 25% (15/59) of Avant-Garde, 17% (4/23) of Slim low-risk, and in 15% (4/26) of TSU patients. On average a first bDMARD was started later in the Slim arms, more specifically at week 69 for Classic, week 106 for Slim high-risk, week 97 for Avant-Garde, week 102 for Slim low-risk and week 76 for TSU.

Conclusion

The combination of MTX with a GC bridging scheme (COBRA Slim) was more cost-effective (less expensive with comparable disease control) than more intensive step-down combination strategies or a conventional step-up approach 5 years after initial treatment. Over 5 years, around one-fifth of all patients, were in need of starting biological treatment and the transition to a bDMARD was later in COBRA Slim. These results point out the possibility of an early “economic” window of opportunity for diminishing costs long-term while still maintaining optimal disease control.

Disclosure of Interests

None declared

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial

Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

P–696 The duration of estrogen treatment prior to frozen-blastocyst transfer does not impact live birth rate

Study question

Does the prolonged duration of oestrogen treatment prior to frozen-blastocyst transfer (FET) affect live birth rate?

Summary answer

Variation in the duration of estrogen treatment prior to frozen-blastocyst transfer does not impact live birth rate.

What is known already

With improvements in cryopreservation techniques and fertility preservation, single embryo transfer policy and the increase in freeze-all cycles, frozen blastocyst transfer (FET) has strongly risen over the last years. Artificial endometrial preparation (AEP) is often used prior to FET. The endometrium is prepared by a sequentially treatment of estrogen and progesterone in order to synchronize endometrium and the embryo development. Whether the duration of progesterone administration before FET is well established, the optimal estrogen treatment duration remains controversial.

Study design, size, duration

All consecutive frozen thawed autologous blastocyst transfer cycles conducted between January 1, 2012 and July 1, 2019 in our University IVF center were included in this retrospective cohort study. We included 2235 single blastocyst FET cycles prepared with hormonal replacement therapy using oral E2 and vaginal progesterone administration in 1376 patients aged from 18 to 43 years.

Participants/materials, setting, methods

Patient’s characteristics, stimulation characteristics, FET cycles characteristics and cycles outcomes were anonymously recorded and analyzed. Univariate and multivariate analysis were performed. At first, each FET cycle was analyzed individually and secondly taking into account that some of the patients had undergone several FET, the model considered the number of implanting attempts for each woman.

Main results and the role of chance

We found no significant difference in the mean duration of estradiol administration before frozen embryo transfer between the group live birth versus non-live birth (27.0 ± 5.4 days versus 26.6 ± 5.0 days ; p=0.11). Endometrial thickness was not significantly different between the 2 groups (8.3 ± 1.7 mm versus 8,2 ± 1,7 mm ; p = 0.21). When the duration of estradiol exposure was analyzed in weeks, we observed no difference for the £ 21 days group (OR = 0.97 ; IC 0.64–1.47 ; p = 0.88), 29–35 days group (OR = 0.89 ; IC 0.68–1.16 ; p = 0.37) and &gt; 35 days group (OR = 0.75 ; IC 0.50–1.15 ; p = 0.10) compared to the reference group (22–28 days). After multivariate analysis, the duration of estradiol treatment before frozen embryo transfer did not affect live birth.

Limitations, reasons for caution

The relatively limited numbers of cycles with more than 35 days or less than 21 days as well as the retrospective design of the study are significant limitations.

Wider implications of the findings: Variation in the duration of estradiol supplementation before progesterone initiation does not impact FET outcomes. We therefore can be reassuring with our patients when E2 treatments need to be extended, allowing flexibility in scheduling the day of transfer.

Trial registration number

Not applicable

POS0616 LONG-TERM EFFECTIVENESS AFTER MULTIPLE CYCLES WITH RITUXIMAB FOLLOWING AN ON-FLARE RETREATMENT STRATEGY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rituximab is known as an efficacious drug for the treatment of Rheumatoid Arthritis (RA). The recommended administration schedule consist of 2 infusions of 1000 mg with a 2-week interval. In Belgium an on-flare retreatment strategy is followed, making evaluation of effectiveness over time challenging. Moreover the patient’s view on this strategy is unclear.

Objectives:

To explore long-term effectiveness and safety of rituximab in daily clinical practice in patients with RA.

Methods:

Data of patients diagnosed with RA and treated with rituximab in a tertiary university hospital were retrospectively collected. For every cycle, clinical data were recorded at the time of the first and second infusion, the 16-week visit and the visit on which the treating rheumatologist decided to prescribe a new cycle. Data on demographics, previous RA treatment, disease activity, patient-reported outcomes, adverse events related to rituximab, dose and number of cycles were collected from 01/01/2006 until 01/12/2019 or until discontinuation of rituximab. The visit on which rituximab was prescribed for the first time was considered as the baseline visit. The data were analysed descriptively.

Results:

Data of 66 patients with RA were collected. The median (IQR) age was 57.0 (47.0-65.0) years at baseline and 56% (37/66) were female. Most patients were seropositive (RF 91% and ACPA 92%), and had erosive (71%) or nodular disease (53%). The median (IQR) disease duration was 12.5 (4.0-18.3) years. In total, 94% of the patients had failed at least one other biological Disease-modifying Antirheumatic Drug (bDMARD) before starting rituximab. Overall, patients received a median (IQR) of 3 (2-7) cycles of rituximab. Seven of the 66 patients (11%) discontinued rituximab and changed to another bDMARD after a median (IQR) of 1 (1-6) cycles and 11% were treated with a lower dose than 2x1000mg. The median (IQR) interval between the first 2 cycles was 7.0 (6.0-10.0) months, after which this increased to up to one year (interval between cycle 2-3: 10.0 (7.0-13.0) months, cycle 3-4: 12.0 (7.3-15.5) months). The overall median (IQR) follow-up time was 45.5 (14.8-82.3) months. The efficacy of rituximab remained after repeated cycles: after every treatment with rituximab, a reduction in disease activity based on the disease activity score in 28 joints (DAS28) could be noticed (figure 1A). The evolution in patients’ (PaGH) and physicians’ global health (PhGH) assessment followed the same pattern as the DAS28-score (Figure 1B). High PaGH-scores could be noticed at every start of a new rituximab cycle. The proportion of patients with a PaGH-score above 20 ranged from 84% - 100%, 74% - 100% and 66% - 86% at the first infusion, second infusion and week 16 visits, respectively. Rituximab was considered to be well-tolerated. In total, 23 adverse events in 12 patients were recorded and none of them were serious.

Conclusion:

Rituximab can be considered a highly efficacious drug for RA treatment in daily practice. There were no major side effects and there was an increasing treatment interval over time. However, a healthy survivor effect should be kept in mind when interpreting the results. It should be noted that with the on-flare retreatment strategy, every new rituximab cycle was preceded by a rise in PaGH-scores, which reflects a state of impaired wellbeing reported by patients. This should be further studied with qualitative methods and in a randomized trial setting comparing on-flare with fixed-interval retreatment to evaluate optimal effectiveness.

Figure 1.

Evolution in median - interquartile range disease activity (DAS28CRP) (A) and patients’ (PaGH) and physicians’ global health (PhGH) (B) over the different rituximab cycles. The disease activity, PaGH and PhGH were measured at baseline, the time of the first and second infusion, W16 and the visit on which a new rituximab cycle was prescribed. The dotted lines represent a DAS28CRP-score of 2.6 (remission cut-off) and 3.2 (low disease activity cut-off). C: cycle; W: week; VAS: visual analogue scale.

Disclosure of Interests:

None declared

AB0109 VALIDATION OF SEPARATE PATIENT-REPORTED, CLINICAL AND LABORATORY FACTOR SCORES AS REPRESENTATION OF DISEASE BURDEN IN A POPULATION WITH ESTABLISHED RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) can cause important bio-psychosocial burden. When exploring disease burden evolution in the 2-year Care in early RA (CareRA) trial, 3 factor scores were extracted via exploratory factor analysis (EFA).1 EFA uncovers the fact that multiple observed variables have similar patterns of responses because they are all associated with a latent, not directly observable, variable.

Objectives:

To validate in a population with established RA, the 3 factors scores and their individual components originally extracted in CareRA.

Methods:

Patients with established RA in sustained remission under treatment with etanercept (≥1 year) were enrolled in the TapERA (Tapering Etanercept in RA) trial between 2012 and 2014. Patients completed the Flare Assessment in RA (FLARE-RA) questionnaire.2

Components of disease activity scores (swollen/tender joint count, physician and patient global health assessment, CRP and ESR), as well as pain (question 2) and fatigue evaluation (question 8), from the FLARE-RA questionnaire, and HAQ were recorded at every visit (v=5).

Missingness on previously mentioned variables was handled with multiple imputation (100 imputations). Pain and fatigue were re-scaled from their original Likert scale of 1-6 to 0-100 to match CareRA data. Next, timepoint clustering was removed with multiple outputation (1000x) and each of the 100 000 datasets was analyzed by EFA with principal component extraction and oblimin rotation. The analyses were combined after re-ordering the factors by maximizing factor congruence.

Results:

Sixty-six patients with a mean disease duration of 14.8 years (SD 9.03), mean age of 55.21 years (SD12.87), 96% (63/66) positive to RF or ACPA, 77% (51/66) with erosions and 68% (45/66) female were included in this analysis.

Table 1 provides the results of the EFAs from CareRA and TapERA. The factor structure and factor components remained the same in both datasets. The factor loadings, indicating how strongly a variable relates to its factor (correlation between observed and latent score), were also comparable. The HAQ, however; did have a stronger factor loading in TapERA (0.57 vs 0.92).

Table 1.

Results from the exploratory factor analyses in CareRA and TapERA

VariableCareRATapERAPRFCFLFPRFCFLFFatigue0.900.80PaGH0.870.81Pain0.860.75HAQ0.570.92SJC280.920.82TJC280.890.84PhGH0.760.60CRP0.870.85ESR0.780.82

Factor loadings presented (correlation between the observed score and the latent factor). Cross-loadings were negligible (<0.3) -not presented. The factor order is by % of variance explained.

PRF: patient-reported factor, CF: clinical factor, LF: laboratory factor, PaGH: patient’s global health assessment, HAQ: health assessment questionnaire, SJC28: 28 swollen joint count, TJC28: 28 tender joint count, PhGH: physician’s global health assessment, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate

Conclusion:

The latent factor structure for disease burden originally found in CareRA was successfully validated in the TapERA dataset, underlining the robustness of the PRF, CF and LF scores. HAQ seems to take “greater importance” on established RA. However, deviations in factor loadings (e.g., HAQ) could be attributed to differences between study populations (e.g., early vs. established RA, sample size). Apart from traditional clinical and laboratory factors, patient-reported pain, fatigue, functionality and overall well-being determine disease burden, both in early and established RA. Using these factor scores could facilitate detection and management of patient’s unmet needs.

References:

[1]Pazmino, et al. Does Including Pain, Fatigue, and Physical Function When Assessing Patients with Early Rheumatoid Arthritis Provide a Comprehensive Picture of Disease Burden? J Rheumatology 2020 Nov.

[2]Berthelot JM, et al. A tool to identify recent or present rheumatoid arthritis flare from both patient and physician perspectives: the ‘FLARE’ instrument. Annals Rheumatic Diseases. 2012.

Disclosure of Interests:

None declared

POS0503 THE DISCORDANCE BETWEEN PATIENT-REPORTED AND CLINICAL/BIOLOGICAL OUTCOMES COULD HELP IN PREDICTING FUTURE DISEASE IMPACT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Treatment of Rheumatoid Arthritis (RA) has improved significantly based on early treat-to-target (T2T) strategies. Still, decreased health related quality of life (QoL), restricted ability to work and other unmet needs are reported by RA patients even in the absence of disease activity. We previously identified 3 factors representing the broader impact of RA using exploratory factor analysis: a patient-reported factor (patients global health, pain, fatigue and HAQ), a clinical factor (physician’s global health, tender and swollen joint count), and a laboratory factor (ESR and CRP)1.

Objectives:

To test whether the discordance between patient-reported (PRF) and clinical(CF)/laboratory(LF) measures can predict QoL, or has a mediating effect in predicting future disease burden based on disease activity (DAS28CRP).

Methods:

This is a post-hoc analysis of the 2-year CareRA trial. PRF, CF and LF scores were calculated as weighted (by factor loading) sum of their components at week 16, 52 and 104 after treatment initiation. A discordance score (DS) between PRF and the mean of the other two scores was also computed.

Mediation analyses were fitted to test the hypothesis (Figure 1) that DS could be a mediator for predicting PRF, CF and LF at a future time point (week 16, 52 and 104) using DAS28CRP at a previous time point (baseline and week 16). Confidence intervals were estimated via 10 000 bootstraps. Finally, a linear regression was fitted for DS to predict future QoL (RAQoL questionnaire; range 0-30; higher values indicating worse QoL).

Results:

Patients with early RA (n=379) were included with a mean (SD) age of 53.9 (13.0), 77% seropositive and 69% women.

The DS was shown to be mediating the effect of DAS28CRP on any future PRF (Table1). On the other hand, there was no mediation effect of the DS in the prediction of the CF and an inconsistent mediation effect when predicting the LF.

Moreover, the DS at week 16 significantly predicted (p<0.0001) RAQoL scores at year 1 with an effect of β 19.05 (SE 1.58) and an R2 of 0.30 (CI 0.22-0.38). Similarly, it predicted RAQoL (p<0.0001) at year 2 with a β 19.74 (SE 1.56) and R2 of 0.32 (CI 0.24-0.40).

Table 1.

Results of mediation analyses for prediction of future burden based on previous DAS28CRP and mediated by discordance.

TimepointPredictor variablesDirect Effect95% CIsR2Mediation effect Patient-reported factorW16DAS28CRP at BL-0.0091-0.0240, 0.00580.1450PresentDS at BL0.0246*0.0169, 0.03310.1784W52DAS28CRP at W160.0215*0.0010, 0.04190.3394PartialDS at W160.0580*0.0442, 0.07390.2749W104DAS28CRP at W160.0101-0.0102, 0.03050.2798PresentDS at W160.0528*0.0396, 0.06860.2749Clinical factorW16DAS28CRP at BL0.0153*0.0074, 0.02320.0599AbsentDS at BL0.0019-0.0010, 0.00480.1784W52DAS28CRP at W160.0365*0.0267, 0.04630.1944AbsentDS at W160.0034-0.0031, 0.00950.2749W104DAS28CRP at W160.0115*0.0024, 0.02070.0409AbsentDS at W160.0033-0.0019, 0.00890.2749Laboratory factorW16DAS28CRP at BL0.0063*0.0015, 0.01110.0634PartialDS at BL0.0030*0.0012, 0.00500.1784W52DAS28CRP at W160.0003-0.0063, 0.00680.0305PresentDS at W160.0051*0.0012, 0.00960.2749W104DAS28CRP at W16-0.0007-0.0079, 0.00640.0014AbsentDS at W160.0013-0.0019, 0.00460.2749

W: week BL: baseline DS: discordance score

DAS28CRP: disease activity score in 28 joints with C-reactive protein

*p<0.01

Conclusion:

Early discordance between patient-reported and biological/clinical factors mediates the effect of disease activity on future patient-reported outcomes, but also predicts QoL. Paying attention to this early discordance might provide opportunities to prevent patient’s unmet needs by additional non-pharmacological interventions, hence broadening the scope of T2T.

References:

[1]Pazmino S, et al. Does Including Pain, Fatigue, and Physical Function When Assessing Patients with Early Rheumatoid Arthritis Provide a Comprehensive Picture of Disease Burden? J Rheumatol. 2020 Nov 15:jrheum.200758. doi: 10.3899/jrheum.200758. Ahead of print.

Disclosure of Interests:

None declared

POS0266-HPR PATIENT-PERCEIVED ASPECTS OF RA FLARE EVOLVE OVER TIME, AS REFLECTED BY THE FLARE-RA QUESTIONNAIRE: POST-HOC ANALYSIS OF TAPERA

Background:

Flares are common in rheumatoid arthritis (RA). While flares negatively impact clinical and patient-reported outcomes, different aspects of disease activity may constitute a flare to patients. Flare Assessment in RA (FLARE-RA) is a patient-reported questionnaire aiming to detect active or recent RA flares (1). During its validation, arthritis and general health subscales were identified and the instrument was adapted from 13 questions (1-6 Likert scale) to 11 questions (0-10).

Objectives:

To investigate which patient-perceived aspects of flare are assessed by FLARE-RA in the context of a TNFi-tapering trial, using exploratory factor analysis (EFA).

Methods:

Patients with RA in DAS28CRP/ESR-remission (≥6 months) and treated with etanercept 50 mg weekly (≥1 year) were included in the 12-month TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial between 2012 and 2014. Participants completed 3-monthly FLARE-RA questionnaires.

The first and final follow-up visits (M3 & M12) were analyzed. Missing data were imputed with multiple imputation (n = 10). Sampling adequacy was assessed by Kaiser-Meyer-Olkin (KMO) and correlations between variables were evaluated with Bartlett’s sphericity test. Spearman correlation matrices were constructed in each of the 10 imputed datasets. The pooled matrix was then analyzed by EFA with principal component extraction and promax-rotation. EFA aims to identify clusters of questions that elicit similar responses because of association with the same underlying latent (not observable) constructs/factors.

Results:

Sixty-six patients (68% female) with a mean age of 55 years (SD 13) and a mean disease duration of 14.8 years (SD 9) completed a total of 330 FLARE-RA questionnaires. Sampling adequacy was acceptable (KMO = 0.94) and correlation between items was sufficient for factor analysis (p < 0.001).

Table 1 shows the results of EFA in TapERA compared to the validation study (1). Factor loadings indicate how strongly each item correlates with its underlying factor. EFA of the full 13-item FLARE-RA at M3 revealed 3 factors: Arthritis, General health and a Medication factor relating to management of flare. The Arthritis factor explained the largest proportion of variance (31%). EFA at M12 showed the same underlying factors, but a less robust factor structure (cross-loadings >0.3) and a larger proportion of variance explained by the General health factor (33%).

Conclusion:

FLARE-RA assessed similar patient-perceived aspects of RA flare within the context of a TNFi-tapering trial when compared to the validation study, including a Medication factor reflecting use of both glucocorticoids and analgesics. This underlines the usefulness of FLARE-RA in providing a multi-faceted view of patients’ conceptions of RA flare. However, these aspects and their relative importance do seem to evolve over time. Further research is needed to assess if this is due to the influence of time or specific to the studied population/tapering setting.

References:

[1]Fautrel B, et al. Validation of FLARE-RA, a Self-Administered Tool to Detect Recent or Current Rheumatoid Arthritis Flare. Arthritis Rheumatol. 2017;69(2):309–19

Table 1.

Factor loadings (>0.3) from exploratory factor analysis of the 13-question FLARE-RA collected in TapERA, compared to results from the FLARE-RA validation study (1). Factors presented in descending order of % variance explained. Q5 & Q7 were removed in the final FLARE-RA.

ITEMFLARE-RA ValidationTapERA M3TapERA M12GFAFAFGFMFGFAFMFQ1: stiffness0.330.750.930.73Q2: pain0.470.650.911.00Q3: swelling0.350.800.920.93Q4: nocturnal pain0.390.820.670.76Q5: overall0.390.840.860.86Q6: analgesics0.360.810.680.470.51Q7: glucocorticoids0.910.96Q8: fatigue0.680.510.700.87Q9: limitation0.730.480.300.750.74Q10: irritability0.850.390.770.69Q11: mood0.830.440.970.79Q12: withdrawal0.900.891.06Q13: needing help0.810.380.720.600.30Variance explained (%)6610313112333110

AF = arthritis factor, GF = general health factor, MF = medication factor

Disclosure of Interests:

None declared

FRI0035 THE CHALLENGE OF ASSESSING WELL-BEING IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS

Background:

Advances in therapeutics and treatment strategies for Rheumatoid Arthritis (RA) have improved clinical outcomes. Although these advances also impact the well-being as shown in many patient-reported outcomes, still a sizeable number of patients in clinical remission report a reduced well-being.

Objectives:

To explore factors that contribute to well-being in patients with early RA.

Methods:

Patients from the 2-year pragmatic treat-to-target Care in Early Rheumatoid Arthritis (CareRA) trial were included. Patients were treated intensively, with a combination of csDMARDs and glucocorticoid remission induction schemes, except one group treated with MTX monotherapy.

Eight different validated questionnaires including the Arthritis Self-Efficacy Scale (ASES), the multidimensional Fatigue Inventory (MFI), the Pittsburgh Sleep Quality Index (PSQI) the Revised Illness Perception Questionnaire (IPQ-R), the Utrecht Coping List (UCL), the Short Form 36 (SF-36), RA Quality of Life questionnaire (RA-QOL) and the Social Support List (SSL) were taken. Questionnaires were obtained at baseline, at week 16, 52 and 104 except for the IPQ and UCL, which were only taken at baseline and week 16.

Three patients` groups were created including all patients, patients in remission (DAS28crp < 2.6) and not in remission. Regression models were constructed to define well-being at week 16, 52 and 104. The Patient Global Assessment (PGA) on a Visual Analogue Scale 0-100 (VAS) was chosen as a proxy for well-being (score 0-100). As predictors, all subscales of the 8 validated questionnaires, summing to 84 variables, with and without the VAS for Pain (VAS-Pain) were used in 18 models (3 patient groups, 3 time points, with/without VAS-Pain) in total. Data reduction used forward, backward and stepwise selection based on the Aikake information criteria. Data was checked for influential observations by Cook’s distance and for multicollinearity by variance inflation factors (threshold = 5). Influential observations were removed one observation every time. Highly correlated variables were deleted by backward selection (α=5%). Missing data was handled by multiple imputation using CART with 15 iterations.

Results:

In total, 379 patients were included. Table 1 gives the number of variables and the associated R2. In the 9 models defining well-being without VAS-Pain, 53 variables were used at least once. Most common variables were bodily pain (n=8) and social function (n=5) of the SF-36, and positive emotions (n=4) of the SSL. In the 9 models with VAS-Pain, 31 variables were used at least once. Most common variables were vitality (n=3) and social function (n=3) of the SF-36, and identity (n=3) of the IPQ-R. Model content was heterogenous regarding patient population and time.

R2and number of variables in each model of well-being

All patientsPatients in remissionPatients not in remissionR2#R2#R2#week 1652%1339%753%6week 16 with VAS-Pain78%469%680%5week 5244%844%757%12week 52 with VAS-Pain84%584%692%2week 10440%1339%862%10week 104 with VAS-Pain81%782%486%11

R2= coefficient of determination, the proportion of the variance in the dependent variable that is predictable from the independent variable(s). # = number of variables selected in regression model

Conclusion:

Well-being is apparently difficult to define uniformly as many factors contribute to it. As already known, well-being, defined by PGA, and VAS-Pain are highly associated, even in patients in remission where pain levels should be theoretically lower. Other well-being definitions could lead to different results and should be further explored.

Disclosure of Interests:

Diederik De Cock: None declared, Tianna Poffe: None declared, Geert Verbeke: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

FRI0566 THE FLARE-RA QUESTIONNAIRE CAN IDENTIFY OMERACT FLARES IN PATIENTS WITH RHEUMATOID ARTHRITIS INCLUDED IN THE TAPERA TRIAL

Background:

The Flare assessment in rheumatoid arthritis (FLARE-RA) questionnaire has been developed to identify flares in patients with rheumatoid arthritis (RA). The first version was published by Berthelot et al. (2012) and consisted of 13 questions on a Likert-scale of 1-6 ranging from ‘completely untrue’ to ‘completely true’. When the FLARE-RA questionnaire was validated by Fautrel et al., 2 questions were removed, and it was rescaled to 0–10. The questionnaires’ usefulness has been tested in few studies. Further external validation in a well-defined cohort of patients with RA is needed.

Objectives:

To externally validate the FLARE-RA questionnaire and determine cut-offs for identifying a flare in an established RA population in which biologicals are tapered.

Methods:

Patients who were in remission according to the DAS28CRP or ESR (≥6 months) and treated with etanercept 50 mg weekly (≥1 year), were enrolled between 2012 – 2014 in the pragmatic 1-year open-label randomised controlled TapERA (Tapering Etanercept in RA) trial. Patients were randomised to continue etanercept 50 mg weekly or taper to 50 mg every other week. The FLARE-RA questionnaire (version of 2012) was completed every 3 months. Outcomes were based on 3 versions of the questionnaire (13 questions (13q), 11 questions (11q) and 11 questions rescaled (r11q)). Per time point, the average of the answers was calculated to obtain a total score of the FLARE-RA questionnaire. The total scores were compared between patients in remission (DAS28CRP <2.6), low (DAS28CRP ≥2.6 - ≤3.2), moderate (DAS28CRP >3.2 - ≤5.1) and high disease activity (DAS28CRP >5.1) using the Kruskal-Wallis test and between patients with and without a flare according to the OMERACT definition (increase in DAS28 >1.2 compared to baseline or increase in DAS28 >0.6 and current DAS28 ≥3.2) using the Mann-Whitney U test. The total FLARE-RA scores of the different time points were combined to determine the receiver operating characteristics (ROC) curves, the corresponding cut-off values and the area under the curve (AUC) for identifying an OMERACT flare. An AUC of <0.5, between 0.5 and 0.7 and >0.7 stands for having no, moderate and a good predictive value, respectively.

Results:

FLARE-RA questionnaires of 66 patients (68% female, mean ± standard deviation (SD) age of 55 ± 11 years) were collected. The FLARE-RA score (13q) did increase when disease activity increased at month (M) 3 and M12 (p<0.01) (table 1). Patients presenting with an OMERACT flare had a statistically significantly higher total FLARE-RA score (13q) compared to patients without a flare, except at M12 (M3 and M6: p<0.05, M9: p<0.01). The AUC - ROC curve of the FLARE-RA questionnaire (13q) for identifying an OMERACT flare was 0.736 and the cut-off value was 2.3 (1-6 scale). The AUC - ROC curve was the same for the 11q and r11q version, namely 0.727. The cut-off values were 2.4 (1-6 scale) and 2.7 (0-10 scale), respectively (figure 1).

Table 1.

Comparison of the total FLARE-RA scores (13q) between the disease activity groups (DAS28CRP)

RemissionLDAMDAHDAP-valueBLPatients (n)62310FLARE Q1.8 ± 0.81.5 ± 0.31.30.800M3Patients (n)501150FLARE Q2.1 ± 1.03.0 ± 0.93.5 ± 1.40.004M6Patients (n)52590FLARE Q2.1 ± 0.83.1 ± 1.33.1 ± 1.90.057M9Patients (n)481071FLARE Q2.1 ± 0.92.8 ± 1.13.3 ± 1.62.40.079M12Patients (n)52860FLARE Q2.1 ± 1.03.1 ± 0.83.2 ± 1.00.002Figure 1.

ROC curves of the total FLARE-RA scores (13q, 11q and r11q version) for identifying a flare according to the OMERACT definition. FLARE Q is expressed in mean ± SD. M month, FLARE Q FLARE-RA questionnaire 13q, n number, LDA low disease activity, MDA moderate disease activity, HDA high disease activity

Conclusion:

The FLARE-RA scores seem to reliably discern between patients with and without an OMERACT flare. A cut-off of 2.7 on the current questionnaire (r11q) had the optimal sensitivity and specificity to identify an OMERACT flare.

Disclosure of Interests:

Delphine Bertrand: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Diederik De Cock: None declared, Anneleen Moeyersoons: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Johan Joly: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

FRI0020 CLINICAL TREATMENT RESPONSE STILL DOES NOT MATCH PATIENT REPORTED IMPROVEMENT, EVEN IN EARLY RHEUMATOID ARTHRITIS

Background:

Commonly used disease activity scores in rheumatoid arthritis (RA) include one patient reported outcome (PRO) -the patient’s global health assessment (PGA). Exploratory factor analysis (EFA) was performed on data from the 2 year Care in early Rheumatoid Arthritis (CareRA) trial to explain the evolution of disease burden extracting 3 factors.1

Objectives:

To assess the evolution and relative responsiveness over time of clinical, laboratory and patient assessments included in composite scores, together with other PROs like pain, fatigue and functionality in patients with early RA (≤1 year) treated to target (T2T) within the CareRA trial.

Methods:

DMARD naïve patients with early RA (n=379) were included, randomized to remission induction with COBRA-like treatment schemes (n=332) or MTX monotherapy (n=47) and T2T.

Components of disease activity scores (swollen/tender joint count (S/TJC), C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), and physician (PhGH) or patient (PGA) global health assessment), pain and fatigue (both on 0-100 scale) and HAQ were recorded at every visit.

Missing data was handled with multiple imputation (n=15). Clustering was removed with multiple outputation (n=1000), then each of the 15 000 datasets was analyzed by EFA with principal component extraction and oblimin rotation. The analyses were combined after re-ordering the factors by maximizing factor congruence. The 3 extracted factors and their individual components (with their loadings) were: 1. Patient containing PGA (0.87), pain (0.86), fatigue (0.90) and HAQ (0.5) 2.Clinical with SJC (0.92), TJC (0.89) and PhGH (0.76) and 3.Laboratory with CRP(0.87) and ESR (0.78).1(Pazmino, ACR 2019 abstract, Table 3)

Afterwards, variables were first normalized to a 0-1 scale, then multiplied -weighted- by the factor loadings previously obtained.1For each Patient, Clinical and Laboratory severity score, the weighted variables belonging to each score were summed together and then re-scaled to 0-1 (higher values suggest more burden).

The percentage (%) improvement from baseline to week 104 and the area under the curve (AUC) across time points were calculated per factor.

Differences in % improvement and AUC were compared between patients not achieving and achieving early and sustained (week 16 to 104) disease activity score remission (DAS28CRP <2.6) with ANOVA. Bonferroni correction was used for multiple testing.

Results:

Severity scores of Patient, Clinical and Laboratory factors improved rapidly over time (Figure 1). In patients achieving sustained remission (n=122), Patient, Clinical and Laboratory scores improved 56%, 90% and 27% respectively. In patients not achieving sustained remission (n=257) the improvement was 32%, 78% and 9% respectively (p<0.001 only for clinical improvement).

Patients in CareRA who achieved sustained remission had an AUC of 15.1, 3.4 and 4.7 in Patient, Clinical and Laboratory scores respectively, compared to 32.3, 10.0, and 7.2 in participants not achieving sustained remission (p<0.001 for all comparisons).

Conclusion:

Patient, Clinical and Laboratory severity scores improved rapidly over time in patients achieving rapid and sustained disease control. However, overall, Patient burden seemed not to improve to the same extent as Clinical burden. Patient’s unmet needs in terms of pain, fatigue, functionality and overall well-being should thus be given more attention, even in patients in sustained remission.

References:

[1]Pazmino S,et al.Including Pain, Fatigue and Functionality Regularly in the Assessment of Patients with Early Rheumatoid Arthritis Separately Adds to the Evaluation of Disease Status [abstract]. ACR. 2019.

Disclosure of Interests:

Sofia Pazmino: None declared, Anikó Lovik: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department), Diederik De Cock: None declared, Veerle Stouten: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

FRI0023 TREATING EARLY AND INTENSIVELY IS ASSOCIATED WITH LOWER FATIGUE LEVELS ON THE LONG TERM, EVEN IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS CONSIDERED TO HAVE A FAVOURABLE RISK PROFILE

Background:

Fatigue is reported in up to 90% of patients with established Rheumatoid Arthritis (RA). Fatigue has a large impact on patient`s life and is perceived difficult to manage in many patients. The early disease course could constitute a window of opportunity to tackle fatigue.

Objectives:

To explore that, if RA can be controlled rapidly, complaints of fatigue could be less in the long run, even in patients considered at low risk to develop a severe disease course.

Methods:

Patients with a low risk profile recruited in the 2-year pragmatic Care in Early Rheumatoid Arthritis (CareRA) trial were used in this analysis. This low risk profile was based on the absence of erosions, rheumatoid factor, anti-citrullinated protein bodies or low disease activity status. The low-risk group was randomised to either a tight step-up starting with 15mg MTX weekly in monotherapy (MTX-TSU) or COBRA Slim, consisting of 15 mg MTX weekly and a prednisone step-down scheme starting at 30 mg. Fatigue was measured by the multi-dimensional fatigue inventory (MFI), a self-report instrument consisting of 20 questions with a Likert scale from 1-5 as answer. These 20 questions can be subdivided in five subscales (0-20) of four questions (higher scores indicating higher fatigue levels): general fatigue, mental fatigue, physical fatigue, reduced activity and reduced motivation. General fatigue means the general feeling of being tired. Mental fatigue implicates concentration and memory problems. Physical fatigue implicates a lack of energy and strength. Reduced activity means that patients can do less activities for example on one day. Reduced motivation means that patients don’t want to plan or do things due to lack of motivation. MFI was obtained at baseline, at week 16, week 52 and week 104. Cobra Slim was compared with MTX-TSU by Mann-Whitney-U test. The 5 domains of the MFI of the two groups were compared by a generalized estimating equation (GEE) over 2 years adjusting for baseline MFI domain score and DAS28.

Results:

Of the 90 patients recruited in the low-risk group, 80 (89%) patients completed the MFI at baseline. Randomisation was successful resulting in similar baseline characteristics and MFI levels between Cobra Slim (n=38) and MTX-TSU (n=42). After 2 years of treatment, DAS28CRP levels (Slim 1.9 ±0.8 - MTX-TSU 2.2 ±1.0, p=0.253) and DAS28CRP remission (Slim 81.5% - MTX-TSU 77.1%, p=0.677) did not differ between patients. However, general (Slim 9.8 ±4.1 – MTX-TSU 13.1 ±4.0, p=0.005) and mental (Slim 6.8 ±2.7 - MTX-TSU 10.0 ±4.9, p=0.022) fatigue levels on the MFI were lower in the Cobra Slim group at week 104. GEE analysis confirmed that groups differed in the general (p=0.026) and mental (p=0.013) fatigue scale over 2 years (Figure 1).

Figure 1.

DAS28CRP and MFI General Fatigue score over 2 years between groups

Conclusion:

Patients treated intensively have lower fatigue levels over 2 years compared to patients treated more conservatively, even if disease activity became similar in the two groups over time. This underlines the importance of initiating an optimal intensive treatment even in so called low-risk patients. Moreover, our results show that fatigue is a heterogeneous concept, with different interactions between treatment and type of fatigue. Although our study was limited by a small sample size, the data clearly shows how to improve fatigue levels significantly in early RA.

Disclosure of Interests:

Diederik De Cock: None declared, Amber Nooyens: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Veerle Stouten: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

THU0214 LONG-TERM EFFECTIVENESS OF METHOTREXATE WITH STEP DOWN GLUCOCORTICOID BRIDGING (COBRA SLIM) VERSUS OTHER CONVENTIONAL DMARD REGIMENS AS INITIAL RA THERAPY: 5-YEAR OUTCOMES OF THE CARERA TRIAL

Background:

The treat-to-target Care in Early Rheumatoid Arthritis (CareRA) trial demonstrated that remission induction with csDMARD combinations and step-down glucocorticoids (GCs) was not superior over methotrexate (MTX) monotherapy with step-down GCs (Cobra Slim) in RA patients with a high-risk profile (1). Moreover, Cobra Slim showed benefit over a tight step-up with MTX in monotherapy (TSU) in RA patients with a low-risk profile.

Objectives:

To compare the long term outcomes up to 5 years of different initial intensive treatment strategies in participants of the CareRA-plus study.

Methods:

In the CareRA trial, patients with DMARD naïve early RA were stratified in a high- or low-risk group based upon the presence of serummarkers, disease activity and erosive status. High-risk patients were randomised to Cobra Classic (MTX+sulphasalazine with highly dosed GC remission induction scheme), Cobra Avant-Garde (MTX+leflunomide with moderately dosed GC scheme) or Cobra Slim. Low-risk patients were randomised to Cobra Slim or TSU. Patients completing this trial were eligible for the CareRA-plus observational study. Here, patients were evaluated 6-monthly over 3 years. Therapy adaptation was left to the treating physician. Efficacy was assessed by DAS28-CRP and HAQ and compared between the originally allocated treatment arms. The 5-year evolution from CareRA baseline of DAS28-CRP and HAQ was assessed via linear mixed models. All adverse events (AEs), considered to be clinically relevant by investigators, and DMARD/GCs therapy were registered.

Results:

Of 322 eligible patients, 252 (78%) were included in CareRA-plus, of which 203 (81%) completed the study. Characteristics and outcomes at the CareRA closing visit (year 2) did not differ between patients entering CareRA-plus or not. DAS28-CRP<2.6 at year 5 in high-risk patients was 72%, 77% and 64% in the Classic, Slim and Avant-Garde group respectively (p=0.403). In the longitudinal analyses, all treatment arms in the high-risk group had comparable DAS28-CRP (p=0.921) and HAQ scores over time (p=0.540). In the low-risk population, 83% of patients in the Slim and 82% in the TSU arm had DAS28-CRP<2.6 at year 5 (p=0.945). Low-risk patients starting Cobra-Slim had lower DAS28-CRP scores over 5 years than those receiving TSU (p= 0.002). HAQ score over time did not differ (p=0.129). In high-risk patients, the total numbers of AEs throughout CareRA-plus, were 70 in 36 Classic, 95 in 48 Slim and 80 in 36 Avant-Garde patients (p=0.182). In the low-risk group there were 18 AEs in 10 Slim and 36 in 17 TSU patients (p=0.048). During the 5-year study, biologics were initiated in 22% of all patients: 23% of Classic, 23% of Slim high-risk, 25% of Avant-Garde, 17% of Slim low-risk, and 15% of TSU patients. At the year 5 visit, 71%, 61% and 50% of high-risk patients were on csDMARD monotherapy (mostly MTX) in Classic, Slim and Avant-Garde respectively. Of the low-risk group, 65% in COBRA-Slim and 62% in TSU were taking a single csDMARD. At the year 5 visit, 9% of all participants received chronic oral GC therapy (>3 months).

Conclusion:

All intensive treatment strategies resulted in excellent long-term clinical outcomes. Initial Cobra Slim therapy showed comparable 5-year effectiveness as Cobra Classic and Avant-Garde in high-risk early RA patients and better efficacy and safety than conservative step up treatment in low-risk patients.

Figure 1.

Mean disease activity by DAS28-CRP or mean functionality by HAQ index scores for high-risk or low-risk patients.

References:

[1]Stouten, V. et al. Effectiveness of different combinations of DMARDs and glucocorticoid bridging in early rheumatoid arthritis: two-year results of CareRA. Rheumatology (Oxford). (2019)doi:10.1093/rheumatology/kez213.

Disclosure of Interests: :

Veerle Stouten: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Diederik De Cock: None declared, Sofia Pazmino: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Kristien Van der Elst: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

SAT0028 THE FLARE-RA QUESTIONNAIRE CAN PREDICT FLARES IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS PARTICIPATING IN THE TAPERA TRIAL

Background:

The Flare assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire was developed to identify Rheumatoid Arthritis (RA) flares, but it is unknown if this questionnaire can also predict flares.

Objectives:

To identify if the FLARE-RA questionnaire has a predictive capacity for OMERACT flares in patients with established RA participating in a tapering trial.

Methods:

Patients, participating in the 1-year open-label pragmatic randomised controlled TapERA (Tapering Etanercept in RA) trial, were included in the analysis. Patients had to be in DAS28CRP or ESR remission (≥6 months) and treated with etanercept 50 mg weekly (≥1 year). Participants were randomised to continue etanercept 50 mg weekly or to taper to 50 mg every other week.

The FLARE-RA questionnaire was completed every 3 months in the trial. This questionnaire consists of 13 questions on a Likert-scale from 1 to 6 reflecting ‘completely untrue’ to ‘completely true’. Validation by Fautrel et al. leaded to elimination of 2 questions (‘steroid intake’ and ‘overall worsening of RA’) and rescaling to 0-10. Our outcomes were based on these 3 versions of the questionnaire, namely 13 questions (13q), 11 questions (11q) and rescaled 11 questions (r11q). The FLARE-RA questionnaire can be divided in 2 subscales: the FLARE-RA arthritis subscale (questions regarding morning stiffness, night disturbances, joint swelling, joint pain, analgesics) and FLARE-RA general symptoms subscale (questions regarding fatigue, functional limitation, irritability, mood disturbances, withdrawal, need for help).

The total FLARE-RA score was calculated by taking the average of all the questions per time point. A flare was defined according to the OMERACT definition, namely an increase in DAS28CRP > 1.2 compared to baseline or increase in DAS28CRP > 0.6 and current DAS28CRP ≥ 3.2. All the total FLARE-RA scores of the baseline, month 3, 6 and 9 visit were grouped and the mean ± standard deviation (SD) FLARE-RA score was compared between patients with or without an OMERACT flare on the next study visit using the Mann-Whitney U test. Logistic regressions using the total FLARE-RA score to predict an OMERACT flare 3 months later were carried out for the 13q, 11q and r11q versions and the FLARE-RA subscales. Missing data were imputed using expectation maximisation.

Results:

Sixty-six patients (68% female, mean ± SD age of 55 ± 11 years) completed the FLARE-RA questionnaire. This yielded 264 FLARE-RA scores, of which the total mean ± SD FLARE-RA score was 2.1 ± 1.0 and 2.7 ± 1.1 for patients without and with an OMERACT flare on the next study visit, respectively (p<0.01). This was comparable for the 11q and r11q versions (Table 1). For the total FLARE-RA score (13q), the odds ratio of having an OMERACT flare 3 months later is 1.6 (95% confidence interval (CI) 1.2 – 2.2, p=0.004). This was 1.5 (95% CI 1.1 – 2.1, p=0.006) for the 11q and 1.2 (95% CI 1.1 – 1.4, p=0.006) for the r11q version. The odds ratio of having an OMERACT flare on the next visit was 1.5 (95% CI 1.2 – 2.0, p=0.002) and 1.4 (95% CI 1.0 – 2.0, p=0.025) for the arthritis and general symptoms subscale, respectively.

Table 1.

Comparison of overall total FLARE-RA scores between patients with or without an OMERACT flare on the next visit

Questionnaire versionNo OMERACT flare on next visitOMERACT flare on next visitP-valueOverall total FLARE-RA score(mean ± SD)13q2.1 ± 1.02.7 ± 1.10.00211q2.2 ± 1.12.7 ± 1.10.004r11q2.3 ± 2.13.4 ± 2.20.004

Overall total FLARE-RA score was derived by grouping the total FLARE-RA scores of the baseline, month 3, 6 and 9 visit.

Conclusion:

Higher total FLARE-RA questionnaire scores seem to indicate a higher risk of an OMERACT flare 3 months later, regardless of which versions or subscales of the FLARE-RA questionnaire were used. Hence, our findings suggest that the FLARE-RA questionnaire could be used as a predictive tool for flares.

Disclosure of Interests:

Delphine Bertrand: None declared, Diederik De Cock: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Anneleen Moeyersoons: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

[Validation of the cervical length education and review program in a population of French residents in obstetrics and gynecology]

OBJECTIVES

Evaluate an educational program based on "CLEAR" (Cervical Length Education and Review) in the teaching of measuring sonographic cervical length to residents in gynecology and obstetrics.

METHODS

This is a prospective cohort study in a tertiary care center between May and November 2017. The residents were asked to collect 5 cervical length images from patients suspected with threatened preterm labor. A theoretical session on cervix measurement image criteria based on "CLEAR" program was taught to all residents. Then, they had to collect 5 new cervical length images. All the images were reviewed by two experienced reviewers, blinded to the resident and whether the image was obtained before or after the theoretical session and based on 8 criteria.

RESULTS

Ten residents participated to the study. The mean total score CLEAR was significantly higher post-intervention: 6.6±0.9 vs. 4.3±2.1, positive difference of 2.3±2.3 (P<0.001). Improvement was most significant with the junior residents: 3.6 pre vs. 6.5 post-intervention.

CONCLUSION

Educational program based on CLEAR criteria allowed to improve the competence of residents in measuring sonographic cervical length, although this can also be correlated with the progression of residents during the semester. It could be implemented systematically with the aim of CLEAR certification to standardize the teaching of residents in gynecology and obstetrics.

Methotrexate in combination with other DMARDs is not superior to methotrexate alone for remission induction with moderate-to-high-dose glucocorticoid bridging in early rheumatoid arthritis after 16 weeks of treatment: the CareRA trial

Objectives

To compare the efficacy and safety of intensive combination strategies with glucocorticoids (GCs) in the first 16 weeks (W) of early rheumatoid arthritis (eRA) treatment, focusing on high-risk patients, in the Care in early RA trial.

Methods

400 disease-modifying antirheumatic drugs (DMARD)-naive patients with eRA were recruited and stratified into high risk or low risk according to classical prognostic markers. High-risk patients (n=290) were randomised to 1/3 treatment strategies: combination therapy for early rheumatoid arthritis (COBRA) Classic (methotrexate (MTX)+ sulfasalazine+60 mg prednisone tapered to 7.5 mg daily from W7), COBRA Slim (MTX+30 mg prednisone tapered to 5 mg from W6) and COBRA Avant-Garde (MTX+leflunomide+30 mg prednisone tapered to 5 mg from W6). Treatment modifications to target low-disease activity were mandatory from W8, if desirable and feasible according to the rheumatologist. The primary outcome was remission (28 joint disease activity score calculated with C-reactive protein <2.6) at W16 (intention-to-treat analysis). Secondary endpoints were good European League Against Rheumatism response, clinically meaningful health assessment questionnaire (HAQ) response and HAQ equal to zero. Adverse events (AEs) were registered.

Results

Data from 98 Classic, 98 Slim and 94 Avant-Garde patients were analysed. At W16, remission was reached in 70.4% Classic, 73.6% Slim and 68.1% Avant-Garde patients (p=0.713). Likewise, no significant differences were shown in other secondary endpoints. However, therapy-related AEs were reported in 61.2% of Classic, in 46.9% of Slim and in 69.1% of Avant-Garde patients (p=0.006).

Conclusions

For high-risk eRA, MTX associated with a moderate step-down dose of GCs was as effective in inducing remission at W16 as DMARD combination therapies with moderate or high step-down GC doses and it showed a more favourable short-term safety profile.

EudraCT number:

2008-007225-39.

A detailed analysis of treatment delay from the onset of symptoms in early rheumatoid arthritis patients

OBJECTIVES

A treatment delay of more than 12 weeks can negatively affect treatment response in rheumatoid arthritis (RA). Our aim was to quantify the different stages of delay before RA treatment in different rheumatology centres and to explore influencing factors.

METHOD

A total of 156 disease-modifying anti-rheumatic drug (DMARD)-naive early RA patients were included from eight practices: one academic hospital, five general hospitals, and two private practices. Eight different types of delay were defined from symptom onset until treatment initiation. Information on the duration of each stage of delay was collected from the patient, their general practitioner (GP), and patient files at the rheumatology practice. Patient/GP demographics and disease activity/severity parameters were recorded.

RESULTS

The median total delay from symptom onset until treatment initiation was 23 weeks whereas patient-, GP- and rheumatologist-related median delay was 10, 4, and 7 weeks, respectively. Only 21.6% of the patients had a total delay of less than 12 weeks. The total median delay in private rheumatology practices was less than in academic and general hospitals (p < 0.001). Furthermore, RA patients treated within 12 weeks of symptom onset showed a higher level of disease activity. The duration of rheumatologist-related delay was inversely correlated with disease activity parameters. Patients with morning stiffness were treated, on average, 3 weeks sooner than those without morning stiffness (p < 0.006).

CONCLUSIONS

In only one out of five early RA patients was treatment initiated within 12 weeks of symptom onset, as recommended. Patient-related delay contributed most to overall delay. Disease activity and type of rheumatology centre are pivotal determinants of delay.