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Objective Although treat-to-target (T2T) strategies are effective in early rheumatoid arthritis (RA) patients, important individual variations exist in the course toward remission. Growth mixture modeling provides more insight into this heterogeneity by identifying subgroups of patients with similar response patterns. This study aimed to identify distinct trajectories of disease activity in early RA patients following a T2T strategy during their first year. Methods Data on various clinical and patient-reported measures were collected from the Dutch Rheumatoid Arthritis Monitoring remission induction cohort. Growth mixture modeling was applied to examine the impact of T2T on subgroups characterized by different types of growth trajectories, as measured with the Disease Activity Score in 28 joints. Results Three distinct trajectories of disease activity were found. The normative trajectory contained most patients (82.6%), showing a quickly decreasing disease activity that stabilized at remission after 9 months. This group performed best on clinical and patient-reported measures over time and were more likely to be men. A smaller group (14.1%) also approached remission, but demonstrated a slower response to treatment. Finally, a minority (3.3%) showed no improvement after 1 year, despite an initial quick decrease in disease activity during the first months of treatment. Conclusion Disease activity in early RA patients during the first year of a T2T strategy does not follow a linear pattern, nor is a single developmental trajectory applicable to all patients. Future studies should attempt to identify more specific risk factors for poor outcome to enable early identification of patients in need of alternative therapeutic approaches.

Contains fulltext : 110623.pdf (Publisher’s version ) (Closed access) OBJECTIVE: For cost-utility analyses of health technologies, utilities are commonly measured with the EuroQol-5D (EQ-5D) or the Short Form 6D (SF-6D). Although most studies in rheumatoid arthritis (RA) found the SF-6D to be more responsive than the EQ-5D, evidence is not convincing. The aim of this study was to compare the responsiveness of the EQ-5D and SF-6D to improvement in RA patients treated with tumor necrosis factor (TNF) blockers. METHODS: Data from 278 RA patients included in the Dutch Rheumatoid Arthritis Monitoring registry were used. Internal responsiveness over 1 year was evaluated by using standardized response means (SRMs). External responsiveness was evaluated by using receiver operating characteristic curves based on perceived health change (self-reported health transition item Short Form 36) and change in disease activity (European League Against Rheumatism response criteria based on the Disease Activity Score in 28 joints). RESULTS: The scores of the EQ-5D and SF-6D changed moderately over 1 year (SRMs 0.50 and 0.67, respectively). The SF-6D was significantly more responsive to treatment than the EQ-5D. The EQ-5D and SF-6D were moderately able to correctly classify patients according to health transition (areas under the curve [AUCs] 0.67 and 0.72, respectively) and change in disease activity (AUCs 0.71 and 0.65, respectively). CONCLUSION: The EQ-5D and SF-6D were only moderately responsive to improvement in RA patients treated with TNF blockers. Overall, the SF-6D was more responsive than the EQ-5D. 01 juni 2012

Item does not contain fulltext Objectives. To evaluate the prevalence of clinical remission and minimal disease activity according to the ACR/European League Against Rheumatism (EULAR) remission, DAS-28 1 occurred in, respectively, 67, 69 and 0% of the patients. Modification of the cut-point of the patient-reported outcome increased the prevalence of ACR/EULAR remission, but also the level of disability. Conclusion. MDA and DAS-28

Item does not contain fulltext Objective. The use of TNF inhibitors leads to an increased risk of serious infections in RA. Predicting this risk would facilitate the prevention of serious infections. The objective of this study was to identify which factors are predictive of the increased risk of serious infections in RA patients treated with TNF inhibiting therapy. Methods. Data from the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry of 2044 patients with RA were used for the analyses. Data were censored at stopping TNF inhibitors or end of observation time up to 5 years. Univariate and multivariate analysis of baseline variables was performed using Cox regression with time to the first serious infection as dependent variable. Results. During a follow-up time of 5 years, 128 of 2044 (6.3%) patients developed a first serious infection with a total of 141 serious infections. The incidence rate in the first year after start of TNF inhibiting therapy was 4.57 first serious infections per 100 patient-years and 2.91 per 100 patient-years over 5 years. Age, corticosteroid use, visual analogue scale (VAS) pain, HAQ, tender joint count 28 joints (TJC28) and the presence of comorbidities were significant predictors for developing a serious infection during TNF inhibiting therapy in the multivariate model. Conclusion. Age, corticosteroid use, VAS pain, HAQ, TJC28 and the presence of comorbidities all at baseline were significant predictors for developing a serious infection during TNF inhibiting therapy in RA patients.

Rheumatoid arthritis (RA) is characterized by chronic inflammation of the joints. It is important to suppress disease activity as soon as possible. Clinical trials have shown that a treat-to-target (T2T) approach is effective in lowering disease activity and, ultimately, in reaching remission in early RA. T2T aims to control and suppress disease activity to a predefined target as quickly as possible, by protocolised adaptation of the treatment if the target is not met, thereby making optimal use of the currently available medications and computer aids. The question remained whether these beneficial results could be translated into daily clinical practice. The objective of this thesis was to explore the effects of implementing a T2T strategy aiming at remission in early RA. For this purpose, we started the Dutch Rheumatoid Arthritis Monitoring (DREAM) remission induction cohort, the results of which are presented in this thesis. The goal of treatment was to achieve a state of remission (Disease Activity Score in 28 joints (DAS28) < 2.6), thereby following a medication protocol with therapeutic adjustments based on the DAS28. The implementation of a T2T strategy aiming at DAS28 remission resulted in beneficial clinical outcomes in very early RA: the majority of patients achieved remission and this often occurred early in the disease process. This resulted in limited radiological damage, improved physical functioning and improved quality of life. T2T was more effective in achieving remission than usual care treatment. Moreover, T2T was cost-effective. Since T2T and aiming at remission have been shown to be feasible in daily clinical practice, such treatment approaches should be embraced to optimize clinical outcomes for patients with early RA.

Contains fulltext : 108181.pdf (Publisher’s version ) (Closed access) There is strong evidence from clinical trials that a 'treat to target' strategy is effective in reaching remission in rheumatoid arthritis (RA). However, the question is whether these results can be translated into daily clinical practice and clinical remission is a reachable target indeed. OBJECTIVE: The study aims to investigate whether in early RA a treatment strategy aiming at Disease Activity Score (DAS) 28

Background Modern treatment strategies are highly successful in reducing disease activity in rheumatoid arthritis (RA). However, changes in clinical measures of disease activity may not always correspond with a patient’s own opinions of improvement. Objectives To identify subjective predictors of self-reported health changes in patients with a good clinical response after one year of treatment in a tight control study. Methods Data from newly diagnosed patients of the Dutch Rheumatoid Arthritis Monitoring (DREAM) remission induction cohort who completed baseline and 12 months assessments was used for this study. Patients who achieved a good DAS28 response at 12 months were selected for analysis 1 . Subjective change in health was assessed with the SF-36 health transition question (Compared to one year ago, how would you rate your health in general now?). Scores were dichotomized (improved vs not improved) for analysis. Binary logistic regression analysis was performed to identify predictors of patient reported health changes. Twelve month changes in DAS28 scores was added as predictor in the first step; changes in scores on SF-36 subscales were added in a second step. The general health scale of the SF-36 was excluded. Cohen’s standardized effect size (e.s.) statistic (d) was calculated for 12 month change scores of significant predictors and compared between improvers and non-improvers Results A good DAS28 response after 12 months of treatment was achieved by 162 (57%) out of 282 patients. Of these, 40 (24.7%) did not consider their health to have improved since starting treatment (non-improvers). Baseline SF-36 subscale scores did not significantly differ between improvers and non-improvers. Twelve month change scores in bodily pain (OR = 1.03, p = 0.04) and vitality (OR = 1.03, p = 0.04) were significant multivariate predictors of self-reported health improvement. About 19% of the variance in self-reported health changes was explained by the final model (Nagelkerke’s R 2 = 0.19), whereas the model containing only DAS28 change scores explained about 6% of variance (Nagelkerke’s R 2 = 0.06). Mean (SD) bodily pain scores improved from 38.9 (± 18.6) to 74.7 (±19.8) over 12 months for improvers (e.s.= 1.87) and from 41.8 (±19.8) to 62.9 (±19.6) for non-improvers (e.s.= 1.06). Mean (SD) vitality scores improved from 52.8 (±19.8) to 66.7 (±16.8) in improvers (e.s. = 0.71) and from 53.12 (±18.9) to 56.56 (±18.9) for non-improvers (e.s. = 0.17). Conclusions The majority of patients with a good DAS28 response after one year of tight control treatment also considered their health to have improved. However, a substantial minority did not consider their health to have improved, despite significant clinical improvements in disease activity. These results suggest that clinical improvements do not necessarily equate to improved subjective health. One possible explanation is that pain and fatigue are patient reported outcomes that may not be adequately represented in current clinical outcome measures in RA research. References Fransen J, van Riel PL. The Disease Activity Score and the EULAR response criteria. Clin Exp Rheumatol 2005;23(5 Suppl 39):S93-9. Disclosure of Interest None Declared

Rheumatoid arthritis: Monitoring serum concentration of infliximab might improve RA disease control