The performance of matrices in daily clinical practice to predict rapid radiologic progression in patients with early RA

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Abstract

Objective

To compare in daily clinical practice the reliability of matrices that forecast rapid radiologic progression (RRP) at year one, at year two, and over 2 years in patients with early rheumatoid arthritis (RA).

Methods

Overall, 74 early RA patients with X-rays of hands and feet at baseline, year one, and year two were included. Initial DMARD combination therapy with steroids (ICTS) or DMARD monotherapy (IMT) was initiated according to patients' RA severity, based on rheumatologist opinion. The images were scored via the modified Sharp/van der Heijde (SvH) method. A total Sharp score progression of equal or higher than five per year was considered RRP.

Six matrices were tested: ASPIRE CRP/ESR matrices, the BEST matrix, two SWEFOT matrices, and the ESPOIR matrix. Patients were placed in each of them yielding a RRP probability. The performance was tested by Area Under the Curve analysis reflecting the predictive value.

Results

Four patients developed RRP in year one, five in year two, and four over 2 years. With regard to face validity, the predicted probability did not correspond to the risk in reality: the one ICTS patient who developed RRP over 2 years was always found in the lowest RRP categories of all matrices. The ASPIRE CRP matrix yielded at least a moderate predicting value for the three time points. The other matrices showed moderate to no predicting value.

Conclusion

The performance of all matrices was disappointing and it is impossible to fully rely on the existing matrices in daily clinical practice.

Introduction

One of the most important targets in the management of rheumatoid arthritis (RA) is preventing structural damage and disability in the long term. Many treatment possibilities exist to avert such excessive radiologic progression [1], [2], [3], [4], [5]. However, a physician must decide for each individual patient separately which treatment is optimal. Rapid radiologic progression (RRP) occurs only in a minority of patients with early RA and it is of key importance to detect these patients.

In the last decade, many predicting factors for radiographic progression and RRP were identified, but individually these predictors have only a limited prognostic value [1], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Therefore, composite predicting models, arranged in so-called matrices, were constructed to help the treating physician to detect patients at risk for RRP. Six prediction matrices were identified: the ASPIRE CRP/ESR [20], the BEST [21], the SWEFOT, which has two submodels [22], [23], and the ESPOIR [24] matrices. The ESPOIR matrix was the only model developed in an observational cohort while the others originated from clinical trials. Durnez et al. [25] tested the predictive value of the ASPIRE matrix in a daily-practice early RA cohort and found that it yielded a strong negative predictive value but lacked a positive predictive value. Furthermore, the ASPIRE, the BEST, and the SWEFOT matrices were tested in a cohort of established RA patients and were found to have a limited ability to predict RRP [26]. Fautrel et al. [27] tested the performance of these matrices on the French ESPOIR cohort and concluded that the BEST matrix had the greatest validity to detect RRP in their population.

Our aim was to compare the performance of the existing matrices to reliably predict RRP in an early RA cohort in daily practice in the first year, in the second year, and over a period of 2 years.

Section snippets

Methods

The patient population for this trial was part of an observational cohort at the Department of Rheumatology of the University Hospitals of Leuven. This cohort consisted of consecutive DMARD-naïve, early RA patients, enrolled between 2001 and 2007 [28]. Only patients enrolled in parallel randomized clinical trials (RCT) were excluded. Overall, 74 patients were selected for this study because they had X-rays of hands and feet at baseline, year one, and year two. Patients received initial

Results

Table 2 shows the descriptive statistics at baseline of the total population and of the rapid progressors in the first year, in the second year, and over 2 years. Four patients developed RRP in the first year. Five other patients developed RRP in the second year. Four patients in total had a TSS progression of more than ten points over 2 years. Remarkably, three patients out of these four were common between groups with RRP in the first year and the one with RRP over the two-year study period.

Discussion

In this study, the performance of six matrices to predict RRP in daily clinical practice was analyzed at three time points. The ASPIRE CRP matrix showed the highest discriminating power to predict RRP in our observational cohort of early RA patients. This is in contrast to the findings in the ESPOIR cohort in which the BEST matrix yielded the best predictive value [27]. The overall performance of all matrices was however disappointing in patients with early RA as already demonstrated in

Conclusion

The predicting performance of the six matrices (ASPIRE CRP/ESR, BEST, SWEFOT 1/2, and ESPOIR matrices) to detect risk of RRP was modest at best. The ambiguity in results points to the need to improve the existing matrices or even to build new predicting matrices for use in daily clinical practice. A collaboration to unite several early RA cohorts with various patient profiles would be beneficial to create a prediction matrix in which rheumatologists could trust.

Acknowledgments

We would like to thank Luc Lateur, MD, for analyzing the X-rays of all the patients.

References (34)

  • R.B. Landewe et al.

    COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention

    Arthritis Rheum

    (2002)
  • G. Jones et al.

    The effect of treatment on radiological progression in rheumatoid arthritis: a systematic review of randomized placebo-controlled trials

    Rheumatology (Oxford)

    (2003)
  • M. Korpela et al.

    Retardation of joint damage in patients with early rheumatoid arthritis by initial aggressive treatment with disease-modifying antirheumatic drugs: five-year experience from the FIN-RACo study

    Arthritis Rheum

    (2004)
  • A. Finckh et al.

    Long-term impact of early treatment on radiographic progression in rheumatoid arthritis: a meta-analysis

    Arthritis Rheum

    (2006)
  • D. Kyburz et al.

    The long-term impact of early treatment of rheumatoid arthritis on radiographic progression: a population-based cohort study

    Rheumatology (Oxford)

    (2011)
  • B. Combe et al.

    Prognostic factors for radiographic damage in early rheumatoid arthritis: a multiparameter prospective study

    Arthritis Rheum

    (2001)
  • K.W. Drossaers-Bakker et al.

    Long-term outcome in rheumatoid arthritis: a simple algorithm of baseline parameters can predict radiographic damage, disability, and disease course at 12-year followup

    Arthritis Rheum

    (2002)
  • F.C. Breedveld et al.

    Infliximab in active early rheumatoid arthritis

    Ann Rheum Dis

    (2004)
  • J.S. Smolen et al.

    Evidence of radiographic benefit of treatment with infliximab plus methotrexate in rheumatoid arthritis patients who had no clinical improvement: a detailed subanalysis of data from the anti-tumor necrosis factor trial in rheumatoid arthritis with concomitant therapy study

    Arthritis Rheum

    (2005)
  • E. Lindqvist et al.

    Prognostic laboratory markers of joint damage in rheumatoid arthritis

    Ann Rheum Dis

    (2005)
  • R. Landewe et al.

    Disconnect between inflammation and joint destruction after treatment with etanercept plus methotrexate: results from the trial of etanercept and methotrexate with radiographic and patient outcomes

    Arthritis Rheum

    (2006)
  • J.S. Smolen et al.

    Predictors of joint damage in patients with early rheumatoid arthritis treated with high-dose methotrexate with or without concomitant infliximab: results from the ASPIRE trial

    Arthritis Rheum

    (2006)
  • E. Berglin et al.

    Radiological outcome in rheumatoid arthritis is predicted by presence of antibodies against cyclic citrullinated peptide before and at disease onset, and by IgA-RF at disease onset

    Ann Rheum Dis

    (2006)
  • K.P. Machold et al.

    Very recent onset rheumatoid arthritis: clinical and serological patient characteristics associated with radiographic progression over the first years of disease

    Rheumatology (Oxford)

    (2007)
  • N. Courvoisier et al.

    Prognostic factors of 10-year radiographic outcome in early rheumatoid arthritis: a prospective study

    Arthritis Res Ther

    (2008)
  • G. Mouterde et al.

    Predictors of radiographic progression in the ESPOIR cohort: the season of first symptoms may influence the short-term outcome in early arthritis

    Ann Rheum Dis

    (2011)
  • B.M. Nyhall-Wahlin et al.

    The presence of rheumatoid nodules at early rheumatoid arthritis diagnosis is a sign of extra-articular disease and predicts radiographic progression of joint destruction over 5 years

    Scand J Rheumatol

    (2011)
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