PO:06:092 | Early achievement of remission confers better outcomes than low disease activity in both seropositive and seronegative patients with new-onset rheumatoid arthritis

Clelia Zampaglione^1|2, Ludovico De Stefano^1|2, Federica Sabatelli^1|2, Alessio D'Isanto^1|2, Blerina Xoxi^1|2, Antonio Manzo^1|2, Carlomaurizio Montecucco^1|2, Serena Bugatti^1|2. | ¹Department of Internal Medicine and Therapeutics, University of Pavia, Pavia; ²Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.

Background. Although remission is the ideal target in patients with rheumatoid arthritis (RA), stringent definitions are difficult to achieve. In the absence of clear data demonstrating the real benefit of remission over low disease activity (LDA), the two targets often remain interchangeable in clinical practice. Aim of our study was to compare the outcomes of patients with early RA achieving remission vs LDA, taking into account possible differences in relation to autoantibody status.

Methods. Data were retrieved from a monocentric inception cohort of patients with new onset (symptoms <12 months) RA, tightly followed at 3-months intervals and treated to achieve a target of LDA (DAS28 <3.2). Patients achieving remission (DAS28 <2.6) within month 6 and month 12 from treatment start were compared with those in LDA for clinical and functional outcomes at 1 year. These included: inflammatory remission (swollen joint count – SJC28 and C-reactive protein – CRP- levels both < or =1); resolution of pain (VAS pain < or =20 mm and < or =10 mm); normalization of physical function (HAQ <0.5). Analyses were stratified for positivity of anti-citrullinated protein autoantibodies (ACPA).

Results. From a total cohort of 816 patients with new-onset RA, 759 (93%) had at least 6 months of follow-up and were considered for analyses. Of these, 218 (28.7%) achieved early DAS28 remission within month 6, and 176 (23.2%) were in LDA. An additional proportion of 8.7% and 9.2% achieved remission and LDA, respectively, at later points within month 12. Early remission and LDA differed significantly in inflammatory variables, such as SJC28 (mean [range] 1.2 [0-7] vs 2.2 [0-12], p<0.001) and CRP (mean [range] 0.3 [0-3.7] vs 0.5 [0-6.2] mg/dl, p=0.006). Differences were confirmed in both ACPA-positive and -negative patients. In contrast, at later time points, LDA had similar inflammatory burden as compared with remission (mean SJC28 ~1.5 in both), in spite of worse patient-reported outcomes (mean [SD] PGA 25.7 [25] vs 16.6 [21.1], p=0.04). Early achievement of remission was associated with significantly better 1 year outcomes than LDA, including suppression of inflammation, resolution of pain, and normalization of physical function (Figure 1A-D). The benefits of early remission over LDA were confirmed in both ACPA-positive (Figure 1E-H) and -negative patients (Figure 1I-L). In contrast, when remission was achieved at later time points, the advantages over LDA were no longer detectable (data not shown).

Conclusions. Early remission is an achievable target that confers better outcomes as compared with LDA in patients with both seropositive and seronegative RA. Our data reinforce the concept that, in clinical practice, all patients with new-onset RA should be intensively managed and brought to remission in the first 6 months.