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Treat-to-target strategies aiming at additional ultrasound remission is associated with better control of disease activity and less flare in rheumatoid arthritis

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Abstract

Introduction

Treat-to-target (T2T) strategy has greatly improved the prognosis of rheumatoid arthritis (RA). However, the additional benefit of targeting ultrasound (US) remission in addition to clinical remission has been debated.

Methods

RA patients in clinical remission or low disease activity were enrolled. They were assorted into two groups according to the principle of T2T strategy adopted. In clinical group, treatment decision was made with the aim of maintaining DAS28(ESR) ≤ 3.2 only, while in clinical US group, the aim was to attain total power Doppler (PD) US score = 0 in addition to DAS28(ESR) ≤ 3.2. The time-averaged DAS28, flare, and changes of treatment strategy were compared.

Results

One hundred ninety-four patients completed 1-year follow-up, with 100 in clinical US and 94 in clinical group. Compared to clinical group, time-averaged DAS28 in clinical US group was significantly lower (1.89 ± 0.51 vs. 2.33 ± 0.71, P < 0.01) with less flare (20.0% vs. 36.2%, P < 0.05). Furthermore, at the end of 1 year, significantly more patients successfully achieved step-down therapy (66.0% vs. 44.7%, P < 0.01) and dramatically fewer patients with step-up therapy in the clinical US group (13.0% vs. 25.5%, P < 0.05) compared to clinical group. In clinical US group, baseline DAS28(ESR) > 2.29, presence of subclinical synovitis, and step-down strategy were independent risk factors for relapse after clinical remission or low disease activity was achieved.

Conclusions

An US-driven T2T in addition to current clinical remission strategy is associated with better control of the disease activity, reduction of relapse, as well as long-term step-down therapy. Step-down strategy should be carefully applied to the patients with baseline DAS28(ESR) over 2.29 and presence of subclinical synovitis even after they have achieved clinical remission or low disease activity.

Key Points

• Targeting ultrasound remission in addition to current T2T strategy is associated with a better control of RA.

• Step-down strategy should be cautiously considered in those with DAS28(ESR) > 2.29 and baseline subclinical synovitis after they have achieved clinical remission or low disease activity.

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Acknowledgments

The authors thank all the colleagues in our department for their kind cooperation in this project and the patients for participating in this study.

Funding

This work was supported by the National Natural Science Foundation of China (Grant Nos. 81901646, 81771740, 81971524) and Beijing Natural Science Foundation (7184251).

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Authors and Affiliations

  1. Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China

    Yan Geng, Liujun Wang, Xiaohui Zhang, Lanlan Ji, Xuerong Deng & Zhuoli Zhang

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  1. Yan Geng
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  2. Liujun Wang
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Correspondence to Zhuoli Zhang.

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Geng, Y., Wang, L., Zhang, X. et al. Treat-to-target strategies aiming at additional ultrasound remission is associated with better control of disease activity and less flare in rheumatoid arthritis. Clin Rheumatol 40, 113–121 (2021). https://doi.org/10.1007/s10067-020-05186-1

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  • DOI: https://doi.org/10.1007/s10067-020-05186-1

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