Newswise — In early inflammatory arthritis, higher rates of remission are achieved if treatment is started early with conventional therapies and patients are more closely followed, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Boston.

Using the Toronto Early Arthritis CoHort, a prospective observational cohort of 103 patients with early inflammatory arthritis, investigators set out to determine how many patients reached remission 12 months after the initiation of DMARD (disease-modifying antirheumatic drug) therapy. Investigators also compared the different methods of measuring remission currently in use by clinicians.

The average age of the patients was 46 years, and 80% were female. All had symptoms of early arthritis for more than six weeks but for less than 12 months, and all had two or more swollen joints or one swollen joint in the hand plus one additional symptom of arthritis (e.g., morning stiffness). Fifty-nine percent of patients in the cohort initiated combination DMARD therapy (methotrexate plus another DMARD such as sulfasalazine or hydroxychloroquine); 40 percent started only methotrexate. The methotrexate dose was somewhat higher than usually reached, with 35 percent of patients taking 20 to 25 mg per week. At six and 12 months, 13 percent and 28 percent of the patients had initiated biologic therapy, respectively. By 12 months, only 20% of patients required biologic therapies.

While some remission criteria are more stringent than others, at the end of the 12 month period approximately half of the patients were able to achieve remission as a result of having prompted started an optimal DMARD therapy.

"This study highlights the benefits of early DMARD therapy, ideally in combination, using a higher dose of methotrexate," said Vivian Bykerk, MD, University of Toronto, and lead investigator in the study. "However further investigations are needed to identify those who will and will not benefit from this initial strategy and those who require a more aggressive treatment strategy."

The American College of Rheumatology is the professional organization of and for rheumatologists and health professionals who share a dedication to healing, preventing disability and curing arthritis and related rheumatic and musculoskeletal diseases. For more information on the ACR's annual meeting, see http://www.rheumatology.org/annual.

Editor's Notes: Dr. Bykerk will present this research during the ACR Annual Scientific Meeting at the Boston Convention and Exhibition Center from 9:00 " 11:00 am ET on Thursday, November 8, 2007, in the Exhibit Hall. Dr. Bykerk will be available for media questions and briefing at 8:30 am ET on Saturday, November 10 in the on-site press conference room, Room 251. Presentation Number: 293

High Proportion of Remission Can be Achieved Using Initial Early Optimal DMARD Therapy in Patients with New Onset Inflammatory Arthritis

Vivian Bykerk, Shahin Jamal, Chistopher Kitamura, Hong Chen, Edward Keystone. University of Toronto, Toronto, ON, Canada

Background: There remains controversy as to how to best define remission in patients with inflammatory arthritis as reflected by the number of proposed definitions to date. 1,2 The greatest likelihood of achieving remission is in patients with early inflammatory arthritis (EIA) and early rheumatoid arthritis(ERA). The Toronto Early Arthritis CoHort (TEACH) is a prospective observational "real world" cohort of patients with early inflammatory arthritis (EIA) evaluated every three to 6 months according to a standard protocol. Subjects are treated with optimal DMARDs at the outset, followed every 3 months with the goal of reaching remission as determined by the gestalt of the clinician who aims to reach zero swollen joints.

Objectives: The objectives of this study were to determine the proportion of patients in an EIA cohort who reach remission 12 months after initiation of DMARD therapy and to compare different methods of measuring remission.

Methods: Patients were recruited to TEACH according to the following criteria: >16 years old, symptoms for >6 weeks and < 12 months, and 2 or more swollen joints or 1 swollen MCP or PIP and 1 of: positive RF, anti-CCP, AM stiffness > 45 min, a response to NSAID or painful MTP squeeze test, no other connective tissue disease then RA. Patients were treated according to provincial formulary guidelines with the 59% receiving initial combination DMARD (MTX + hydroxychloroquine ± sulfasalazine) therapy and 40% were given monotherapy (MTX). In both groups, the MTX dose was 20-25 mg weekly (s.c. in 35%). Fewer than 7% initiated biologics. At 6 and 12 months 13% and 28% had initiated biologics.

Results: 103 patients were evaluated. Patient characteristics: mean age 46 years; 80% female, baseline symptom duration 5 months,74% initially fulfilled ACR criteria for RA, 31% were RF positive, 25% erosions at baseline, 52% anti-CCP positive, mean baseline HAQ 0.94 and baseline DAS28 5.3. The following table shows the proportion of patients in remission based on different remission criteria over time.

Remission Criteria Proportion in Remission Baseline (n=103) 6 Months (n=73) 12 Months (n=53)DAS28 ESR (<2.6) 5.3% 23% 31%DAS28 CRP (<2.4) 4.6% 38% 49%SDAI (<3.3) 1% 13% 13%CDAI (<2.8) 1.1% 17% 23%MDA (5/7 criteria) 3.9% 36% 55%

Approximately half of the patients seen in an early arthritis cohort were able to achieve remission starting with an optimal and patient appropriate DMARD strategy. The MDA criteria for remission behave similarly to the DAS28 remission criteria. It is more difficult to achieve the SDAI and CDAI remission criteria. Based on these data there is no rationale for reducing the DAS28 remission criteria below 2.6.

1. Aletaha D. et al. Clinical & Experimental Rheumatology. 23(5 Suppl 39):S100-8, 2005 Sep-Oct.2. Wells GA et al. Journal of Rheumatology. 32(10):2016-24, 2005 Oct.

Disclosure Block: V. Bykerk, Amgen/Wyeth, 2; S. Jamal, None; C. Kitamura, None; H. Chen, None; E. Keystone, None.

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ACR Annual Scientific Meeting