Objectives: To examine the clinical and radiologic outcomes over 2 years in a cohort of 187 RA patients who met the ACR criteria of complete clinical remission (Pinals RS, et al. Arthritis Rheum 1981;24:1308-1315).

Methods: Patients were followed every 3 months. Radiographs of the hands and feet were obtained at baseline and after 2 years. Radiographs were scored for joint damage using the Sharp-van der Heijde scoring (SHS) method (range score 0-448).

Results: Of 180 patients completing the study, 93 (52%) remained in complete remsision (CR), 87 had exacerbation of their RA. If DMARDs were increased, patients were classified as having an exacerbation. Patients who remained in CR over 2 years had significantly fewer tender joints, lower VAS (physician global assessment), lower HAQ scores, lower IgM-RF levels than those suffering an exacerbation. For the entire group the mean SHS at baseline and after 2 years was 49 and 51 (p<.0.0010 respectively. For the subgroup with persistent CR, mean SHS were 52 at baseline and 53 at 2 years (p< 0.004). In the subgroup with exacerbations, mean SHS were 46 and 51 (p<0.001). No significant correlations were seen between radiographic changes and baseline variables. Notably, there were no correlations with DAS (Disease Activity Scale) and VAS.

Editorial Comment: The ability of DMARD agents to induce or maintain CR is controversial. Although CR in RA occurs, the frequency, duration and predictive factors are not accurately known. The ACR criteria for CR is stringent and requires 5 of the 6 criteria for 2 months: no morning stiffness > 15 minutes, no fatigue, no joint pain, no joint tenderness or pain on motion, no soft tissue swelling in joints, ESR < 30 mm/hr (females) < 20 mm/hr (males). It is no surprise that the patients with milder disease were more likely to remain in CR. However it is interesting that patients with seemingly little to no clinically active disease continued to have radiographic progression. The scatter plot of the data is even more impressive with some patients having marked x-ray deterioration despite remaining in CR. It would be interesting to see the SHS split into the component categories of joint space narrowing and erosions. One might see how joint space narrowing would proceed if the cartilage matrix were irreversibly damaged by inflammation. These data highlight the need for markers of disease activity beyond clinical signs and symptoms.

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THU0178 Clinical Significance of Rapid Radiographic Progression in Rheumatoid Arthritis
and
THU0180 Identifying Rapid Radiographic Progressors in Rheumatoid Arthritis
J.B. Wong, C.J. Wong, J.M. Hazes, P.L. Van Riel, F.C. Breedveld, D.M. Van der heiide, B.G. Feagan

Abstracts THU0178 and THU0180 utilize 2 Dutch cohorts of 279 early rheumatoid arthritis (RA) patients with radiographs obtained at year 2 or 3 of their disease and were followed prospectively for 12 years. In THU0178, patients were divided into two groups based on their annual rate of radiographic progression (assessed by modified Sharp scores): rapid (>7.5) vs. non-rapid (<7.5) radiographic progressors. The cutoffs were obtained from the Omeract definition of radiographic progression as smallest detectable difference of 15 (SDD=15) which is based on the random measurement error calculated between observer variation in pairwise radiographic scoring. Clinical parameters significantly associated with the rapid progressors included HLA-DR4+, RF+, higher Ritchie articular indices, higher ESR, higher HAQ, higher DAS and older age. Abstract THU0180 attempted to use these clinical parameters in a prediction model for identfying rapid progressors. In a model in which rapid progressors are predicted with 80% probability, 36% of the rapid progressors would be missed and 21% of the non-rapid progressors would be incorrectly identified as rapid progressors. Abstract THU0178 showed that, over time, the rapid progressor group had higher HAQ scores and higher DAS scores than the non-rapid group.

Editorial Comment: Recent studies of the TNF inhibitors have shown these agents to slow or, in some cases, halt radiographic progression in RA and have placed emphasis on radiographic changes as an important therapeutic outcome. However, the amount of radiographic progression that is clinically significant is unclear. From a practical view, clinicians need to assess whether slowing radiographic progression is worth the risk of more aggressive therapy. Abstract THU0178 addresses the question of whether the rate of radiographic progression seen early in the course of RA can predict long term outcome. Not surprisingly, patients with more rapid radiographic changes have more disability and more disease activity after several years of follow-up. Thus it can be argued that radiographic progression should be an important criteria for aggressive therapy. Abstract THU0180 highlights the need for serial x-rays particularly early in the course of the disease to determine rates of radiographic progression, as there are no clinical parameters to predict which patients will be rapid progressors. These studies raise very important issues that will need to be further evaluated in additional studies.

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