Verstappen M, Niemantsverdriet E, Matthijssen X M E, le Cessie S, van der Helm-van Mil A H M
Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
Arthritis Res Ther. 2020 Nov 23;22(1):276. doi: 10.1186/s13075-020-02368-9.
Sustained DMARD-free remission (SDFR) is increasingly achievable. The pathogenesis underlying SDFR development is unknown and patient characteristics at diagnosis poorly explain whether SDFR will be achieved. To increase the understanding, we studied the course of disease activity scores (DAS) over time in relation to SDFR development. Subsequently, we explored whether DAS course could be helpful identifying RA patients likely to achieve SDFR.
772 consecutive RA patients, promptly treated with csDMARDs (mostly methotrexate and treat-to-target treatment adjustments), were studied for SDFR development (absence of synovitis, persisting minimally 12 months after DMARD stop). The course of disease activity scores (DAS) was compared between RA patients with and without SDFR development within 7 years, using linear mixed models, stratified for ACPA. The relation between 4-month DAS and the probability of SDFR development was studied with logistic regression. Cumulative incidence of SDFR within DAS categories (< 1.6, 1.6-2.4, 2.4-3.6, ≥ 3.6) at 4 months was visualized using Kaplan-Meier curves.
In ACPA-negative RA patients, those achieving SDFR showed a remarkably stronger DAS decline within the first 4 months, compared to RA patients without SDFR; - 1.73 units (95%CI, 1.28-2.18) versus - 1.07 units (95%CI, 0.90-1.23) (p < 0.001). In APCA-positive RA patients, such an effect was not observed, yet SDFR prevalence in this group was low. In ACPA-negative RA, DAS decline in the first 4 months and absolute DAS levels at 4 months (DAS) were equally predictive for SDFR development. Incidence of SDFR in ACPA-negative RA patients was high (70.2%) when DAS was < 1.6, whilst SDFR was rare (7.1%) when DAS was ≥ 3.6.
In ACPA-negative RA, an early response to treatment, i.e., a strong DAS decline within the first 4 months, is associated with a higher probability of SDFR development. DAS values at 4 months could be useful for later decisions to stop DMARDs.
持续无病情改善抗风湿药物缓解（SDFR）越来越容易实现。SDFR发生的潜在发病机制尚不清楚，诊断时的患者特征也难以解释是否能实现SDFR。为了增进理解，我们研究了疾病活动评分（DAS）随时间的变化过程与SDFR发生的关系。随后，我们探讨了DAS变化过程是否有助于识别可能实现SDFR的类风湿关节炎（RA）患者。
对772例连续的RA患者进行研究，这些患者迅速接受了传统合成病情改善抗风湿药物（csDMARDs，大多为甲氨蝶呤并根据治疗目标进行治疗调整）治疗，以观察SDFR的发生情况（无滑膜炎，在停用DMARDs后持续至少12个月）。使用线性混合模型，按抗环瓜氨酸肽抗体（ACPA）分层，比较了7年内发生和未发生SDFR的RA患者的疾病活动评分（DAS）变化过程。采用逻辑回归研究4个月时的DAS与SDFR发生概率之间的关系。使用Kaplan-Meier曲线直观显示4个月时不同DAS类别（<1.6、1.6 - 2.4、2.4 - 3.6、≥3.6）内SDFR的累积发生率。
在ACPA阴性的RA患者中，与未实现SDFR的RA患者相比，实现SDFR的患者在最初4个月内DAS下降明显更显著；-1.73单位（95%置信区间，1.28 - 2.18）对-1.07单位（95%置信区间，0.90 - 1.23）（p < 0.001）。在ACPA阳性的RA患者中，未观察到这种效应，且该组中SDFR的患病率较低。在ACPA阴性的RA中，最初4个月内的DAS下降和4个月时的绝对DAS水平对SDFR发生同样具有预测性。当DAS < 1.6时，ACPA阴性RA患者中SDFR的发生率较高（70.2%），而当DAS≥3.6时，SDFR很少见（7.1%）。
在ACPA阴性的RA中，早期治疗反应，即最初4个月内DAS显著下降，与SDFR发生的较高概率相关。4个月时的DAS值可能有助于后续停用DMARDs的决策。
Zotero 插件
