title: Does combined clinical and ultrasound assessment allow selection of individuals with rheumatoid arthritis for sustained reduction of anti-tumor necrosis factor therapy?
abstract: OBJECTIVE
  To investigate whether a strategy combining clinical and ultrasound (US) assessment can select individuals with rheumatoid arthritis (RA) for sustained dose reduction of anti-tumor necrosis factor (anti-TNF) therapies.
  
  
  METHODS
  As part of a real-world approach, patients with RA receiving anti-TNF therapies were reviewed in a dedicated biologic therapy clinic. Patients not taking oral corticosteroids with both Disease Activity Score in 28 joints (DAS28) remission (≤2.6) and absent synovitis on power Doppler US (PDUS 0) for >6 months were invited to reduce their anti-TNF therapy dose by one-third.
  
  
  RESULTS
  Between January 2012 and February 2014, a total of 70 patients underwent anti-TNF dose reduction. Combined DAS28 and PDUS remission was maintained by 96% of patients at 3 months followup, 63% at 6 months, 37% at 9 months, and 34% at 18 months followup. However, 88% of patients maintained at least low disease activity (LDA) with DAS28 <3.2 and PDUS ≤1 at 6 months. The addition of PDUS identified 8 patients (25% of those that flared) in DAS28 remission, with subclinically active disease. Those who maintained dose reduction were more likely to be rheumatoid factor (RF) negative (46% versus 17%; P = 0.03) and have lower DAS28 scores at biologic therapy initiation (5.58 versus 5.96; P = 0.038).
  
  
  CONCLUSIONS
  Combined clinical and US assessment identifies individuals in remission who may be suitable for anti-TNF dose reduction and enhances safe monitoring for subclinical disease flares. Despite longstanding severe RA, a subset of our cohort sustained prolonged DAS28 and PDUS remission. LDA at biologic therapy initiation and RF status appeared predictive of sustained remission.
authors.affiliation: University Hospital Southampton, Southampton, UK.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Marks
authors.affiliation: University Hospital Southampton, Southampton, UK.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Holroyd
authors.affiliation: University of Southampton, Southampton, UK.
authors.forename: Borislav D
authors.initials: BD
authors.lastname: Dimitrov
authors.affiliation: University Hospital Southampton, Southampton, UK.
authors.forename: Ray D
authors.initials: RD
authors.lastname: Armstrong
authors.affiliation: University Hospital Southampton, Southampton, UK.
authors.forename: Antonia
authors.initials: A
authors.lastname: Calogeras
authors.affiliation: University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK, and University of Oxford, Oxford, UK.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Cooper
authors.affiliation: University Hospital Southampton, Southampton, UK.
authors.forename: Brian K
authors.initials: BK
authors.lastname: Davidson
authors.affiliation: University Hospital Southampton and University of Southampton, Southampton, UK.
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Dennison
authors.affiliation: University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Harvey
authors.affiliation: University of Southampton and University Hospital Southampton, Southampton, UK, and University of Oxford, Oxford, UK.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Edwards
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000276:immunology; D001688:Biological Products / Q000008:administration & dosage*; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D007596:Joints / Q000000981:diagnostic imaging* / Q000187:drug effects* / Q000276:immunology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012074:Remission Induction; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D018608:Ultrasonography, Doppler
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha