Thu0646 high Levels of Damage in Inflammatory Rheumatic Diseases: A Clue to Low Rates of Remission and Low Disease Activity

Abstract

BackgroundDespite introduction of powerful biologic medications over the last 2 decades, rates of remission and low disease activity rates in RA remain less than 50%. One possible basis is that measures and indices such as disease activity score 28 (DAS28) and clinical disease activity index (CDAI), while sensitive primarily to disease activity in clinical trial patients selected for high inflammatory activity, may also reflect clinically important joint damage and patient distress in unselected patients in routine care. Similar considerations may pertain to systemic lupus erythematosus disease activity index (SLEDAI), Bath ankylosing spondylitis disease activity index (BASDAI), and other measures and indices initially designed to assess disease activity. Levels of organ damage and patient distress, as well as inflammation, may be quantitated according to 3 physician (0-10) visual analog scales (VAS), in addition to physician global assessment VAS (DOCGL), scored in fewer than 10 seconds in routine care.ObjectivesTo test a hypothesis that damage and distress may be prominent in patients with inflammatory conditions, according to mean VAS for inflammation or reversible findings (DOCINF), damage or irreversible findings (DOCDAM), and distress (DOCSTR), e.g., fibromyalgia.MethodsAll patients at one site complete a multidimensional health assessment questionnaire (MDHAQ), which includes patient global VAS (PATGL), at each visit in routine care. Physicians complete four 0–10 (none-highest) VAS for DOCGL, DOCINF, DOCDAM, and DOCSTR, and a query to estimate the proportion of clinical decisions (total=100%) attributed to each of the 3 findings. Patients were classified into various diagnostic groups, in which scores were analyzed according to mean and standard deviation.ResultsAnalyses included 563 patients (Table). Mean levels of DOCGL ranged from 3.2 to 5.2, and PATGL from 3.6 to 6.5, which might be interpreted to indicate high disease activity. Highest mean DOCINF scores were seen in patients with RA, SLE, vasculitis, polymyalgia rheumatica (PMR), spondyloarthropathy (SpA), and gout (2.2-2.8), while highest mean DOCDAM was seen in OA (4.9) and DOCSTR in FM (6.2) (Table). However, in RA, mean DOCDAM was 3.7 vs 2.4 for DOCINF. DOCDAM also was almost as high or higher than DOCINF in SLE, SpA, vasculitis, and gout. Mean estimates of distress were also ≥1.5 in patients with all inflammatory diagnoses. Diagnosis (per ICD code) N (%) Global Estimates (0-10) Physician subscales (0-10) PATGL DOCGL DOCINF DOCDAM DOCSTR RA644.9 (2.9)4.5 (2.4)2.4 (2.2)3.7 (2.8)1.9 (2.7)SLE474.1 (3.1)3.7 (2.8)2.2 (2.4)1.5 (1.7)1.8 (2.5)SpA and psoriatic arthritis344.1 (2.9)3.9 (2.4)2.4 (2.5)2.7 (2.3)1.9 (2.8)Vasculitis and PMR233.6 (2.6)3.4 (3.0)2.6 (1.8)2.3 (2.2)1.7 (2.6)Gout214.4 (2.9)4.2 (2.7)2.8 (2.5)3.2 (2.8)1.5 (1.9)Osteoarthritis1355.8 (2.9)4.9 (2.2)1.2 (1.9)4.9 (2.5)2.2 (2.7)Fibromyalgia846.5 (2.6)5.2 (2.2)0.9 (1.2)1.7 (2.0) 6.2 (2.6)Other diagnosis1554.0 (3.0)3.2 (2.2)1.6 (2.0)2.4 (2.3)1.6 (2.1)TOTAL5634.8 (3.0)3.9 (2.4)1.6 (2.0)2....