MRI, physical function predict flares after therapy withdrawal in patients with early RA
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Physical function and MRI scores predict flares at 6 and 12 months following the end of treatment with abatacept among patients with early rheumatoid arthritis in remission, according to data published in Arthritis Research & Therapy.
“Achieving remission in patients with RA without the continued use of therapy is a key treatment goal,” Harris Ahmad, MD, senior medical director at WW Medical Affairs at Bristol Myers Squibb, and study co-author, told Healio. “While studies have demonstrated this is possible, this study investigates what factors or measures could predict loss of remission in patients in remission after withdrawing therapy.”
Ahmad and colleagues conducted a post hoc analysis of the AVERT study, investigating abatacept (Orencia, Bristol Myers Squibb)
in patients with early RA. The analysis examined predictors of disease flare at withdrawal plus 6 months and withdrawal plus 12 months with DAS28. The study investigated predictors including the Health Assessment Questionnaire–Disability Index (HAQ-DI), pain, Patient Global Assessment, MRI synovitis, erosion, bone edema and combined — synovitis plus bone edema — inflammation scores.
To be included in the analysis, patients needed to achieve DAS28-based remission at 12 months and enter a 12-month withdrawal period with no treatment with abatacept.
Among the 172 patients who achieved DAS28-defined remission at withdrawal, 100 experienced a flare by withdrawal plus 6 months, the researchers wrote. Meanwhile, a total of 113 patients experienced a flare by 12 months.
Higher Health Assessment Questionnaire-Disability Index scores, MRI synovitis, erosion, bone edema and combined inflammation scores at withdrawal were identified as potential flare predictors in a univariate analysis (P .01), the researchers wrote. In a multivariate analysis, higher Health Assessment Questionnaire-Disability Index scores and MRI erosion were confirmed as independent predictors of flares at withdrawal plus 6 and 12 months (P < .01).
“The take-home message for rheumatologists is that clinical measures, such as MRI and functional status, are available to aid in assessing and predicting which patients in remission may flare following a decision to withdraw therapy takes place,” Ahmad said.
The small sample size and the fact that the included patients represent only a small group of total patients within the AVERT trial were noted as potential limitations of the study.
“As this study was conducted in patients with early RA , future studies will be needed to confirm whether the cut-off scores tested here would also predict disease flare in other RA populations or following the withdrawal or tapering of [biologic DMARDs] other than abatacept,” the researchers wrote.
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Patients with rheumatoid arthritis who are in remission or in low disease activity (LDA) on therapy are a pleasure to see in the office. The patient feels good, and the rheumatologist feels good about the decisions that were made. The question then becomes: What is the next step? Should the patient continue on therapy, or should therapy be withdrawn?
Ahmad, et al., performed a post hoc analysis using data from the phase 3b abatacept (Orencia, Bristol Myers Squibb) AVERT trial to see if certain findings were correlated with a future flare off treatment. Patients received 12 months of treatment and then were tapered off in the next 12 months. The chosen modality for imaging was MRI of the dominant wrist and metacarpophalangeal joints.
Many trials use X-rays and some use ultrasound to make the determination of joint damage. MRI findings that show reduced inflammation have been correlated with a reduction in joint damage. There has been good agreement between ultrasound and MRI in the detection of synovitis, but MRI is considered more sensitive. Both have been shown to be superior to X-rays in detection of early RA.
The use of MRI in decision making regarding treatment withdrawal can be problematic for the practicing rheumatologist. It is recommended that a 3T system be used with a wrist and hand coil. This may not be available, and review of the literature finds no surveys on availability in the community. Payment for the procedure is also likely to be a problem. Most insurance companies are limiting MRI use and each has its own algorithm to decide the need for an MRI. Finally, the expertise of radiologists trained in reading hand and wrist MRIs for RA may also be limited.
The authors also report that Health Assessment Questionnaire-Disability Index (HAQ-DI) scores could predict a flare off treatment. HAQ-DI is readily available and often is available on electronic medical records. I find it helpful to review the HAQ-DI with the patient as it often reveals a more severe burden of disease than I have discerned from other means. This study was a worthwhile exercise to help us decide on the course of treatment for our RA patients. The limitation of MRI use is a challenge for many of us.
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