title: Can flare be predicted in DMARD treated RA patients in remission, and is it important? A cohort study.
abstract: OBJECTIVE
  The treatment target for patients with rheumatoid arthritis (RA) is remission. Imaging techniques and remission criteria may identify patients at risk of flare and associated consequences. This study aimed to determine the clinical, functional and imaging associations of disease flare in patients with RA in remission and any effect on long-term outcomes.
  
  
  METHODS
  RA patients in clinical remission as determined by their treating rheumatologist were assessed using clinical, remission criteria, imaging, functional and quality of life measures over 12 months. Flare was defined as any increase in disease activity requiring a change in therapy.
  
  
  RESULTS
  26% of patients (24/93) in remission experienced a flare within 1 year. Fulfilment of remission criteria was not associated with a reduced likelihood of flare. Increased baseline ultrasound power Doppler (PD) activity (unadjusted OR (95% CI) 4.08 (1.26 to 13.19), p=0.014) and functional disability (Health Assessment Questionnaire Disability Index (HAQ-DI) per 0.1 unit1.27 (1.07 to 1.52), p=0.006) were independently associated with risk of flare. Patients who had a flare had significantly worse long-term clinical (Disease Activity Score 28; mean (95% CI) 2.90 (2.55 to 3.24) vs 2.26 (2.06 to 2.46), p=0.002) and functional outcomes (HAQ-DI; 0.412 (0.344 to 0.481) vs 0.322 (0.282 to 0.362), p=0.029) at 12 months compared with patients in sustained remission.
  
  
  CONCLUSIONS
  The presence of PD activity was the most accurate determinant of flare in RA patients in remission. Flare was associated with worse clinical and functional outcomes. These results suggest ultrasound could form an important part of remission assessment in RA.
authors.affiliation: Divsion of Musculoskeletal Disease, University of Leeds, Leeds, UK.
authors.forename: Benazir
authors.initials: B
authors.lastname: Saleem
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Brown
authors.forename: Mark
authors.initials: M
authors.lastname: Quinn
authors.forename: Zunaid
authors.initials: Z
authors.lastname: Karim
authors.forename: Elizabeth M A
authors.initials: EM
authors.lastname: Hensor
authors.forename: Philip
authors.initials: P
authors.lastname: Conaghan
authors.forename: Charles
authors.initials: C
authors.lastname: Peterfy
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Wakefield
authors.forename: Paul
authors.initials: P
authors.lastname: Emery
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis* / Q000188:drug therapy / Q000517:prevention & control*; D015331:Cohort Studies; D018450:Disease Progression; D057915:Drug Substitution; D005260:Female; D006304:Health Status; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D012074:Remission Induction / Q000379:methods; D055502:Secondary Prevention; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires
chemical_list: D018501:Antirheumatic Agents; D007166:Immunosuppressive Agents