Are prognostic factors adequately selected to guide treatment decisions in patients with rheumatoid arthritis? A collaborative analysis from three observational cohorts

Objective: To investigate the impact of indicators of unfavorable prognosis ("poor prognostic factors") on the achievement of low disease activity (LDA)/remission in patients with rheumatoid arthritis (RA). Methods: Biologic DMARD-naive patients with RA from three observational cohorts were examined. N = 713 patients started their 1st csDMARD, n =1613 switched to the 2nd csDMARD and n = 388 to the 1st TNF-inhibitor. High disease activity (DAS28 > 5.1), autoantibodies (RF/ACPA positive), prevalent erosions, functional limitation (HAQ >= 1.2), comorbidities, obesity (BMI > 30 kg/m(2)), and smoking were evaluated as prognostic factors. Generalized regression analyses were applied to investigate prognostic factors regarding the achievement of LDA (DAS28 < 3.2) or remission (DAS28 < 2.6) within six months. Results: At baseline, RF/ACPA positivity was most frequent in all cohorts (60.3-75.3%), followed by DAS28 > 5.1 (35-57.7%), HAQ >= 1.2 (40.5-52.5%), >= 2 comorbidities (31.4-54.1%) and erosions (17.1-46.1%). Remission was achieved by 39% (1st-csDMARD), 26% (2nd-csDMARD) and 30% (lst-TNFi). In adjusted regression models DAS28 > 5.1 (OR: 0.41 [0.30;0.56]), HAQ >= 1.2 (0.56 [0.42;0.74]), current smoking (0.72 [0.53;0.97], obesity (0.66 [0.49;0.89] and >= 2 comorbidities (0.57 [0.40;0.80]) were independently associated with a lower chance to achieve remission within six months (ORs for 2nd-csDMARD). The proportion of patients in LDA/remission declined by 6-12%-points if DAS28 > 5.1 was present at baseline and by 15-27%-points if functional limitation, comorbidities and obesity were additionally present. In all cohorts RF/ACPA positivity and erosions were not associated with achieving LDA/remission. Conclusions: While RF/ACPA status and erosions do not affect the achievement of LDA/remission, high disease activity, functional limitation, comorbidities and obesity should be considered as unfavorable prognostic factors in patients starting the 1st or 2nd DMARD strategy. (C) 2018 The Authors. Published by Elsevier Inc.