Goal-directed therapy for RA in routine practice is associated with improved function in patients with disease duration up to 15 years
SIR, Improved therapies have dramatically increased our ability to suppress RA disease activity. Short-term goaldirected therapy or treat-to-target, central to the management of hypertension and diabetes, may be the next step to increase effectiveness of RA therapy, although recent recommendations for treat-to-target strategies acknowledge the limited data from routine care (RC) [1]. Nevertheless, inducing remission is a logical short-term goal in RA [2, 3]. Patients receiving DMARDs and achieving low disease states have less joint damage progression [4, 5]. Patient preferences for therapy outcomes consistently identify their priorities as reduced pain and maintenance of function [6, 7]. Our RA Centre service routinely uses goal-directed therapy (GDT) strategy, short-term goal DAS-28 remission (DAS-28< 2.6). After 2 years, we tested if this strategy improved patient function, comparing RA Centre outcomes with those of clinics in the same hospital not using this strategy. An RC group of consecutive patients recruited from clinics where treatment aimed to reduce signs and symptoms with no precise goal, was compared with a matched sample of RA Centre patients, the GDT group. The Guy’s Hospital Research Ethics Committee approved the study and patients gave informed consent. Patients with RA (ACR 1987 revised criteria) [8] over the age of 18 years were recruited for assessment, with no diseaseor comorbidity-related exclusion criteria. Groups were matched within disease duration 2 years, age 5 years and sex. Rheumatologists treating the RC group were not aware of the patient DAS-28 score. HAQ-Disability Index (DI) was not used to guide treatment in either clinic. RC patients were assessed on a single occasion with joint counts and global disease activity performed by a research nurse not involved in therapy decisions. Fisher’s exact tests were used for categorical data, and Wilcoxon signed rank sum tests for paired continuous data, almost all non-normally distributed. Multiple logistic regression assessed clinical factor contributions to achieving remission, and multivariable linear regression assessed influences on HAQ. Analyses were performed using SPSS 15.0 and Graph Pad Prism 5. Ninety patients were recruited to the RC group and data compared with that collected contemporaneously from matched GDT patients. More GDT patients received combination DMARDs (12 vs 3%, P = 0.048) but not biologics (20 vs 13%, P = 0.32). Multiple regression analysis identified DAS-28, age, disease duration and pain VAS as independent predictors of HAQ-DI, with the highest contribution from DAS-28. Patients in the GDT group with disease duration up to 15 years showed significantly improved function compared with RC, with increasingly large differences in patients with shorter disease duration (Fig. 1A). Significantly more GDT patients achieved remission at all disease duration periods (Fig. 1B). Multiple logistic regression including all patients (disease duration up to 30 years) showed males were less likely to achieve remission [odds ratio (OR) 0.3; 95% CI 0.1, 0.8], and patients without erosions were more likely to achieve