Predictors of remission, normalized physical function, and changes in the working situation during follow-up of patients with early rheumatoid arthritis: an observational study.

OBJECTIVES: To evaluate possible predictors of remission, normalized physical function, and work change in rheumatoid arthritis (RA). METHODS: We determined in our early RA cohort the proportion of patients in remission [Disease Activity Score (DAS28)<2.6], with normalized function [Health Assessment Questionnaire (HAQ) = 0], and with changed working situation since disease onset. Candidate predictors of remission, normalized function, and work change were studied by subgroup comparison and logistic regression analysis, including demographics, education, rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, treatment, and DAS28, HAQ, pain and fatigue scores (on the visual analogue scale, VAS). RESULTS: Median (interquartile range, IQR) disease duration was 18 (29) months. Of 89 patients included, 69% were in remission. DAS28, HAQ, pain and fatigue scores of these patients were lower throughout year 1, although similar at baseline, compared to patients not in remission. At month 4, more of these patients were already good responders. Remission at month 4 independently predicted remission at follow-up. Thirty-eight per cent had no functional limitations; compared to patients with limitations, they had a lower baseline HAQ and lower DAS28, HAQ, pain and fatigue scores during year 1. At month 4, more achieved remission or HAQ = 0. Male sex, baseline HAQ, and month 4 good European League Against Rheumatism (EULAR) response predicted long-term HAQ = 0, but month 4 HAQ = 0 was the strongest independent predictor. Of the 40% with a paid job at baseline, 43.8% reported changes in their work situation; they had higher DAS28, HAQ, pain and fatigue scores during year 1. Failing a month 4 good EULAR response independently predicted work change. CONCLUSION: Month 4 disease response predicts later remission, normalized physical function, and work change in RA.

Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis.

OBJECTIVE: To study prospectively the daily practice effectiveness of a step-down early rheumatoid arthritis (RA) treatment strategy. METHODS: Patients with severe RA and no contra-indications were proposed step-down therapy, the others step-up. Step-down patients received a modified combination therapy in early RA (COBRA) regimen: sulphasalazine (SPS), 2 g daily, and methotrexate (MTX), 15 mg weekly, combined with step-down oral prednisolone (start 60 mg daily, fast tapering to 7.5 mg over 6 weeks, discontinuation from week 28). At week 40, patients were randomized to maintenance therapy with either SPS or MTX if disease activity score-28 (DAS28) was acceptably low. The step-up group started disease-modifying anti-rheumatic drug (DMARD) monotherapy. In both groups, treatment was adjusted at follow-up, based on DAS28. DAS28, functionality Health Assessment Questionnaire (HAQ), adverse events, DMARD changes and steroid use were registered 4-monthly for 2 yrs. RESULTS: Nineteen patients received step-down and 52 step-up treatment. More patients completed the first year without unplanned DMARD changes and without dosage adjustment and fewer had DMARD changes due to side effects or inefficacy in the step-down group compared with step-up, whereas the number of adverse events was comparable. MTX proved to be the most effective maintenance therapy after step-down. The DAS response, proportion of patients in remission, HAQ response and proportion of patients without disability at 4 months was higher in the step-down group. CONCLUSIONS: In daily practice, a step-down treatment strategy for early RA is more effective than a step-up approach.

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases.

OBJECTIVE: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. METHODS: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist-epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference. RESULTS: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment). CONCLUSION: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.