Use of a multidimensional RAPID3 questionnaire to assess the achievement of remission and minimal disease activity in patients with early psoriatic arthritis treated according to Treat-to-target strategy

The current Treat-to-target (T2T) strategy in the management of patients with psoriatic arthritis (PsA) is based on strict control over the dynamics of a patient's status and timely correction of therapy according to the presence or absence of remission or minimal disease activity (MDA) within 6 months after treatment initiation. The multidimensional RAPID3 questionnaire based on the patient's own opinion of his/her health status, has demonstrated its high effectiveness in assessing remission in patients with rheumatoid arthritis (RA). The possibilities of using the RAPID3 questionnaire in patients with early PsA (ePsA) with T2T strategy have not yet been studied.
Objective: to investigate whether the multi-dimensional RAPID3 questionnaire may be used to assess the achievement of remission and MDA in ePsA patients with a T2T (Treat-to-target) strategy
Subjects and methods. The investigation enrolled 61 patients (29 men and 32 women) with ePsA meeting the 2006 CASPAR criteria; the mean age of the patients was 37±10.6 years; the duration of PsA and psoriasis was 11.3±10.2 and 75.4±80.9 months, respectively. The patients were followed up for 12 months during the open-label REMARCA study performed by the T2T principles. At baseline, all the patients were given methotrexate (MTX; Methoject) subcutaneously at a dose of 10 mg/week, with escalation by 5 mg every 2 weeks up to 20–25 mg/week. If there was no low disease activity (LDA), DAS28/DAS remission, or MDA after 3 months, the patients received combined therapy with MTX 20–25 mg/week and adalimumab (ADA) or ustekinumab (UST) at standard doses. All the patients underwent standard rheumatologic examination before therapy and every 3 months. The investigators calculated tender joint count (TJC) among 78 joints; swollen joint count (SJC) among 76 joints, the Ritchie articular index, and the number of entheses by the Leeds Enthesitis index (LEI). Joint pain measurement, patient (PGA) and physician (PhGA) global assessment on visual analog scale (VAS) was performed, the serum level of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated. DAS and DAS28, HAQ and RAPID3 functional index were estimated. The number of patients achieving LDA, DAS/DAS28 remission, and MDA were determined.
Results and discussion. At 1 year of therapy, 36 (59%) out of the 61 patients and 25 (41%) out of the 61 patients were treated with MTX and this drug in combination with ADA or UST, respectively. After 1 year of treatment, the whole group displayed a significant improvement of all PsA activity parameters as compared with baseline values: DAS, 3.93 [3.20; 4.58] / 1.36 [0.82; 2.25], SJC, 7 [5; 11] / 1 [0; 3], TJC, 8 [6; 1] / 1 [0; 3], PhGA, 56 [48; 69] / 10 [5; 20] and VAS pain, 54 [48; 68] / 11 [1; 20], PGA, 55 [49; 68] / 14 [7; 24], HAQ, 0.75 [0.50; 1] / 0 [0; 0.63], respectively. There was a significant correlation of RAPID3 with PsA activity and CRP. MDA was seen in 43 (70.5%) out of the 61 patients. Among the patients who had achieved MDA, the RAPID3 values corresponded to remission, but were significantly higher in the patients who had not attained MDA: 2.5 [1.3; 5.3] and 8.1 [6.0; 15.1], respectively. RAPID3 demonstrated high sensitivity in assessing the achievement of remission, LDA, and MDA in patients with ePsA.
Conclusion. RAPID3 based on a patient's personal opinion of his/her disease is a simple and reliable tool to assess the disease activity in patients with ePsA and to monitor the efficiency of therapy with a T2T strategy and may be really useful in practice.

1. Kavanaugh A, Helliwell P, Ritchlin C. Psoriatic arthritis and burden of disease: patient perspectives from the population-based multinational assessment of psoriasis and psoriatic arthritis (MAPP) survey. Rheumatol Ther. 2016;3:91-102. doi: 10.1007/s40744-016-0029-z

2. Coates LC, Helliwell PS. Treating to target in psoriatic arthritis: how to implement in clinical practice. Ann Rheum Dis. 2016;75(4):640-3. doi: 10.1136/annrheumdis-2015-208617

3. Coates LC, Moverley AR, McParland L, et al. Effect of tight control inflammation in early psoriatic arthritis (TICOPA): a UK multicenter, open-label, randomized controlled trial. Lancet 2015;386:2489-98. doi: 10.1016/S0140-6736(15)00347-5

4. Pincus T, Amara I, Segurado O, Koch G. An index based on only patient reported outcome (PRO) measures, routine assessment of patient index data (RAPID3), distinguishes adalimumab from control at levels similar to disease activity score (DAS28) and clinical disease activity index (CDAI). Ann Rheum Dis. 2007;184:66.

5. Pincus T, Bergman MJ, Yazici Y. RAPID3 – An Index of Physical Function, Pain, and Global Status as «Vital Signs» to Improve Care for People with Chronic Rheumatic Diseases. Bull NYU Hospital Joint Dis. 2009;67(2):211-25.

6. Старкова АС, Амирджанова ВН. Валидация русскоязычной версии опросника RAPID-3. Научно-практическая ревматология. 2011;49(4):36-40 [Starkova AS, Amirdzhanova VN. Validation of the russian-language version of the RAPID-3 questionnaire. Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2011;49(4):36-40 (In Russ.)]. doi: 10.14412/1995-4484-2011-36-40

7. Castrejon I, Bergman MJ, Pincus T. MDHAQ/RAPID3 to recognize improvement over 2 months in usual care of patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, as well as rheumatoid arthritis. J Clin Rheumatol. 2013;19(4):169-74. doi: 10.1097/RHU.0b013e3182936b98

8. Castrejon I, Pincus T, Wendling D, et al. Responsiveness of a simple RAPID-3-like index compared to disease-specific BASDAI and ASDAS indices in patients with axial spondyloarthritis. RMD Open. 2016;2:e000235. doi: 10.1136/rmdopen-2015-000235

9. Coates LC, Tillett W, Pincus T, et al. RAPID3 near remission shows good agreement with minimal disease activity criteria in psoriatic arthritis [abstract]. Arthritis Rheum. 2016;68 Suppl 10.

10. Coates LC, Tillett W, Shaddick G, et al. Value of RAPID3 in patients with PsA: results from the TICOPA and LOPAS II databases. Arthritis Care Res (Hoboken). 2017 Nov 7. doi: 10.1002/acr.23460. Epub ahead of print.

11. Taylor WJ, Gladman DD, Helliwell PS, et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54:2665-73. doi: 10.1002/art.21972

12. Коротаева ТВ, Логинова ЕЮ, Каратеев ДЕ и др. Стратегия «Лечение до достижения цели» при раннем ПсА (предварительные результаты исследования РЕМАРКА). Научно-практическая ревматология. 2014;52(4):376-80 [Korotaeva TV, Loginova EYu, Karateev DE, et al. Treat-to-target strategy for early psoriatic arthritis (Preliminary results of the REMARCA study). Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2014;52(4):376-80 (In Russ.)]. doi: 10.14412/1995-4484-2014-376-380

13. Coates LC, Fransen J, Helliwell PS. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis. 2010;69(1):48-53. doi: 10.1136/ard.2008.102053

14. Pincus T, Swearingen C, Wolfe F. Toward a multidimensional health assessment questionnaire (MDHAQ): assessment of advanced activities of daily living and psychological status in the patient friendly health assessment questionnaire format. Arthritis Rheum. 1999;42:2220-30. doi: 10.1002/1529-0131(199910)42:10<2220::AID-ANR26>3.0.CO;2-5

15. Coates LC, Gossec L, Ramiro S, et al. New GRAPPA and EULAR recommendations for the management of psoriatic arthritis. Rheumatology (Oxford). 2017 Aug 1;56(8):1251-3. doi: 10.1093/rheumatology/kew390

16. Smolen J, Schols M, Braun J, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2017;0:1-15. doi: 10.1136/annrheumdis-2017-211734

17. Orbai AM, de Wit M, Mease P, et al. International patient and physician consensus on a psoriatic arthritis core outcome set for clinical trials. Ann Rheum Dis. 2016;0:1-8. doi: 10.1136/annrheumdis-2016-210242

18. Orbai AM, Ogdie A. Patient-reported outcomes in psoriatic arthritis. Rheum Dis Clin North Am. 2016;42:265-83. doi: 10.1016/j.rdc.2016.01.002

19. Coates LC, Helliwell PS. Defining low disease activity states in psoriatic arthritis using novel composite disease instruments. J Rheumatol. 2016;43(2):371-5. doi: 10.3899/jrheum.150826