RESEARCH - Strongest predictor of remission: prompt aggressive treatment

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Medscape Medical News

August 26, 2010

Prompt aggressive treatment improves outcomes in RA

Prompt aggressive treatment is the strongest predictor of remission in

patients with rheumatoid arthritis (RA), regardless of the presence of

poor prognostic factors, according to a new study published in the

August issue of Arthritis Care & Research.

" In the past, the treatment of RA aimed at a reduction of disease

activity to a low disease activity state due to a lack of effective

treatment, " write Wanruchaa Katchamart, MD, from the University of

Toronto, Canada, and colleagues. " With the advent of biologic agents,

the ultimate goal of treatment in RA is now remission in the early

stage of the disease before patients develop permanent deformities,

functional disability and RA-related systemic morbidity and

mortality. "

According to the article, biologic agents can suppress inflammation

and halt radiographic progression, but they also can cause adverse

effects that lead to discontinuation of the medication. In addition,

they are costly. Therefore, being able to identify factors that

predict remission early in the disease would help physicians tailor

their treatment plans to individual patients.

The aim of this study was to summarize the potential predictors of

remission in RA patients.

The researchers reviewed 18 prognostic studies that used multivariate

analysis to identify predictors of remission. They found a number of

independent predictors of remission, including baseline clinical and

laboratory characteristics and genetic markers, as follows:

Male sex

Young age

Late-onset RA (occurring past the age of 65 years)

Short disease duration

Nonsmoker

Low baseline disease activity

Mild functional impairment

Low baseline radiographic damage

Absence of rheumatoid factor and anticitrullinated peptide

Low serum level of acute-phase reactant, interleukin 2, and receptor

activator of nuclear factor κ B ligand (RANKL) at baseline

MTHFR 677T alleles and 1298C alleles in the methotrexate-treated patients

Magnetization transfer ratio 2756A allele ± either the SLC 19A180A

allele or the TYMS 3R-del6 haplotype in the methotrexate plus

sulfasalazine combination-treated patients

Early treatment with nonbiologic disease-modifying antirheumatic

drug (DMARD) combinations

The use of anti–tumor necrosis factor (anti-TNF)

The concurrent use of DMARDs in the anti-TNF-treated patients

Moderate or good response to treatments at the first 6 months

" Although all of the studies included in this review investigated an

independent association using multivariate analysis, the hypotheses of

these studies were usually based on the unreal assumption that the

association between the prognostic factors and RA remission is direct

and isolated, " the study authors write. " This model may be inadequate

to explicitly describe the complex relationship between prognostic

factors and remission for multifactorial and unclear mechanisms of a

disease condition like RA. "

These relationships need to be explored further in phase 3 trials to

better understand the complex prognostic pathways or processes of RA,

the authors conclude.

One author was supported by a Canadian Institutes of Health Research

Clinician Scientist Award; another holds a Canada Research Chair in

Knowledge Transfer for Musculoskeletal Care and has received

consultant fees, speaking fees, and/or honoraria from Schering, Roche,

Biogen Idec, PESI Healthcare, Wyeth, Abbott, and Abbott Canada.

Arthritis Care Res. 2010;62:1128-1143.

http://www.medscape.com/viewarticle/727525

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