Very early rheumatoid arthritis (VERA) is the best predictor of major outcomes: clinical remission and radiographic non-progression

Background: Remission (clinical, laboratory and imaging) is the ultimate goal in early rheumatoid arthritis (ERA).
Objectives: In this study we addressed the issue of whether a very early rheumatoid arthritis (VERA: disease duration less than 3 months) could be the best predictor in a cohort of ERA treated according to a strict protocol, either in terms of clinical remission as well as in terms of x-ray remission (or lack of progression).
Methods: One hundred and twenty-one patients with early RA were treated with Methotrexate (10-20 mg/week) for three months. A combination therapy with subcutaneous anti-TNF was begun after three months if patients did not achieved a low disease activity (DAS ≤2.4). ESR, C-reactive protein, tender and swollen joint count, DAS, HAQ, rheumatoid factor (RF) IgM, RF-IgA and anti-CCP were assessed at baseline and every three months. A patient was considered in EULAR and/or ACR clinical remissions, if he fulfilled the two remission criteria in at least two consecutive visits three months apart. At time 0 and after twelve months of therapy all the patients performed hand and foot radiographs, that were scored according to Larsen method and to a modified Sharp/van der Heijde considering only the erosion score.
Results: 56 (46.3%) of the patients reached DAS remission (DAS44<1.6), and 26 more patients had reached a low disease activity (DAS44≤2.4); 30 patients (24.8%) achieved the ACR remission. More than 70% of patients reached both clinical remissions in monotherapy with methotrexate. In a multivariate analysis the male sex (OR 2.5 [1.1-5.9]) and an ESR <35 mm/h at onset (OR 2.4 [2.2-5.1]) arose as significant predictors of EULAR remission, while a VERA disease (OR 5.3 [2.1-13.0]) resulted the only predictor of ACR remission.
At baseline 28.1% of the patients were erosive. While erosions were present in a similar percentage of patients, who would reach EULAR remission (26.8%) and those who would not (29.2%), radiological damage was less frequent in ACR remission patients (16.7%) with respect to patients who did not reach ACR remission (31.9%). Multivariate analysis demonstrated that the only independent predictor of erosiveness at baseline was "not having a VERA disease" [(OR 3.9 (1.5-10.7)]. After 12 months, despite a tight control therapy approach, 14 patients (11.6%) became erosive and 13 patients (10.7%) presented a worsening of at least one point of Sharp and/or Larsen erosion score.
Conclusion: Our study suggests that a VERA disease represents the best therapeutic opportunity in clinical practice to achieve a complete remission and to stop the erosive course of RA, even though an aggressive protocol cannot allow to completely avoid the radiological progression damage in a small subgroup of patients.