Low Remission/LDA Rates with TNF inhibitors in Rheumatoid Arthritis Save

Analysis of Rheumatoid Arthritis patients enrolled and treated as part of the British Society for Rheumatology Biologics Registry shows that sustained remission or low disease activity state (LDA) on TNF inhibitor treatment is uncommon and that combing methotrexate with an anti-TNF increases the odds of sustained remission/LDA.

The registry enrolled 14,436 RA patients initiating their first TNFi (between 2001 and 2013) with most starting etanercept, infliximab and adalimumab.  Therapeutic choices were at the descretion of the treating physician and disease assessments were done periodically to calculate the 28-joint DAS (DAS28) scores.  RA remission and LDA was defined as achieving the required DAS28-ESR thresholds on two sequential follow-ups (eg, > 6 months) during the first 3 years of data collection. 

Only 15% of RA patients achieved sustained remission and only 26% achieved sustained LDA.

Predictors of sustained remission/LDA included:

• Adalimumab moreso than etanercept
• Higher patient global assessment scores
• Non-smokers (never- and ex-smoker) compared to current smoking
• Higher swollen joint counts
• Combined MTX plus anti-TNF

Negative predictors of sustained remission and LDA included:

• Poor baseline functional status (HAQ)
• Females
• Older age at starting anti-TNF
• Infliximab use 
• Higher BMI
• Higher baseline ESR
• (Higher tender joint counts were negatively associated with sustained LDA only).

The good news is that the number of RA patients achieving sustained remission and LDA increased significantly over time - remission from 14.3-14.9% (2001-2010) to 21.6% (2010-2013), but so did MTX use (56% in 2001–2010 subgroup to 64% in 2010–2013 subgroup). 

During this study period (2001-2013) the time from first rheumatologist consultation to commencement of anti-TNF decreased from 10 to 6 years (P < 0.01).