P.M. ten Klooster

Optimisme en/of pessimisme: factorstructuur van de Nederlandse Life Orientation Test-Revised

SummaryOptimism and/or pessimism: Factor structure of the Dutch Life Orientation Test-RevisedThis study examined the construct validity of the Dutch Life Orientation Test-Revised (LOT-R) in two samples; one sample of patients with psychiatric disorders (n=157) and one sample of patients with rheumatoid arthritis (RA, n=83). Confirmatory factor analyses showed that the LOT-R was not sufficiently unidimensional and could be better explained by two underlying factors consisting of positively and negatively worded items, respectively. This two-factor solution fitted the data significantly better than the one-factor solution in both groups, but satisfied all criteria for good model fit in the psychiatric patient sample only. One-factor models allowing correlated error terms between the positively or negatively worded items performed equally better than the original one-factor solution in both groups, indicating that the two factors may be the result of the specific wording of the items. However, the two factors were differentially associated with other relevant psychological constructs and correlation patterns differed substantially between both populations, indicating possible conceptual differences between optimism and pessimism. Overall, the findings suggest that the positively and negatively worded items of the Dutch LOT-R do not reflect a true unidimensional construct, but two underlying factors which may reflect a complex combination of methodological artefact and substantive differences. Therefore, researchers using the Dutch LOT-R are encouraged to not only rely on total scale scores, but to use additional sub-scores for optimism and pessimism to better examine possible relationships and effects in optimism research.

Psychometric properties of the Rheumatoid Arthritis Disease Activity Index (RADAI) in a cohort of consecutive Dutch patients with RA starting anti-tumour necrosis factor treatment

Objectives: To examine the psychometric properties of the self-administered Dutch Rheumatoid Arthritis Disease Activity Index (RADAI) and its short form (RADAI-SF) in patients with rheumatoid arthritis starting anti-tumour necrosis factor treatment. Method: Internal consistency was assessed with Cronbach’s α. A confirmatory factor analysis (CFA) was carried out to test the single-factor structure. Construct validity was examined by correlating RADAI and RADAI-SF scores with Disease Activity Score in 28 joints (DAS28). Internal responsiveness was evaluated with the paired t test and the standardised response mean (SRM). External responsiveness was assessed with receiver operating characteristic analysis and the SRM, using the EULAR response criterion as external criterion. Change scores were correlated with changes in DAS28. Results: At baseline and after 3 months’ treatment, respectively, 191 and 171 patients completed the RADAI. The internal consistency of the RADAI and the RADAI-SF was satisfactory. CFAs confirmed the single-factor structure of both RADAI versions, but the short form provided the best model fit. Moderate correlations were found with the DAS28. SRMs of the RADAI and the RADAI-SF were, respectively, 0.76 and 0.80. Both versions had moderate accuracy to distinguish responders from non-responders. Changes scores were moderately correlated with DAS28 change scores. Conclusions: This study showed satisfactory psychometric properties of the Dutch version of the RADAI. Omission of the tender joint count (RADAI-SF) produced comparable results and is justified for research purposes. The tender joint count might be useful as additional clinical information in patient management.

Assessment of Fatigue in Rheumatoid Arthritis: A Psychometric Comparison of Single-item, Multiitem, and Multidimensional Measures

Objective. To compare the psychometric functioning of multidimensional disease-specific, multiitem generic, and single-item measures of fatigue in patients with rheumatoid arthritis (RA). Methods. Confirmatory factor analysis (CFA) and longitudinal item response theory (IRT) modeling were used to evaluate the measurement structure and local reliability of the Bristol RA Fatigue Multi-Dimensional Questionnaire (BRAF-MDQ), the Medical Outcomes Study Short Form-36 (SF-36) vitality scale, and the BRAF Numerical Rating Scales (BRAF-NRS) in a sample of 588 patients with RA. Results. A 1-factor CFA model yielded a similar fit to a 5-factor model with subscale-specific dimensions, and the items from the different instruments adequately fit the IRT model, suggesting essential unidimensionality in measurement. The SF-36 vitality scale outperformed the BRAF-MDQ at lower levels of fatigue, but was less precise at moderate to higher levels of fatigue. At these levels of fatigue, the living, cognition, and emotion subscales of the BRAF-MDQ provide additional precision. The BRAF-NRS showed a limited measurement range with its highest precision centered on average levels of fatigue. Conclusion. The different instruments appear to access a common underlying domain of fatigue severity, but differ considerably in their measurement precision along the continuum. The SF-36 vitality scale can be used to measure fatigue severity in samples with relatively mild fatigue. For samples expected to have higher levels of fatigue, the multidimensional BRAF-MDQ appears to be a better choice. The BRAF-NRS are not recommended if precise assessment is required, for instance in longitudinal settings.

Contribution of assessing forefoot joints in early rheumatoid arthritis patients: Insights from item response theory.

To evaluate the contribution of assessing forefoot joints to the measurement range and measurement precision of joint counts in early rheumatoid arthritis (RA) using item response theory.

Zorguitkomsten gezien vanuit de reumapatiënt

SamenvattingTransparantie van zorg en inzicht in resultaten: het wordt steeds belangrijker in de gezondheidszorg. Meten is weten: het geeft zorgaanbieders inzicht in de eigen behandelresultaten en maakt aspecten van kwaliteit van zorg inzichtelijk. Zo beschrijven Patient Reported Outcome Measures (PROM’s) uitkomsten van zorg vanuit het perspectief van de patiënt. De aandacht voor deze PROM’s is groeiende. Medisch Centrum Twente speelt hier op in met een onderzoek naar PROM’s bij reumapatiënten.

THU0071 Radiographic progression in early rheumatoid arthritis patients following initial combination versus step-up treat to target therapy in daily clinical practice: results from the dream registry

Background Early and aggressive targeted treatment with disease modifying anti-rheumatic drugs (DMARDs) has been shown to lead to substantial reductions in disease activity (1,2) and radiologic damage in patients with early rheumatoid arthritis (RA) (3,4). Objectives The aim of this study was to compare the first-year radiographic progression rates between a treat-to-target (T2T) strategy with initial combination therapy (strategy II) versus an initial step-up monotherapy (strategy I). Methods A total of 128 patients from strategy II was individually matched with 128 patients from strategy I on sex, age (± 5 yrs.) and baseline disease activity (± 0.5 on the DAS28). Differences in radiographic progression scores and the number of patients experiencing a minimal clinically important difference (≥5 SHS points; MCID) between both strategies were tested with Mann Whitney U test and chi-square test. Next, linear and logistic regression analyses were performed to examine which baseline variables were associated with radiographic progression scores and the probability of experiencing an MCID within 1 year. Results Patients with initial combination therapy had slightly higher baseline disease activity scores and pain scores, but better mental health scores. Patients with initial monotherapy had significantly more, and more frequently clinically relevant, radiographic progression after one year. Experiencing a MCID was associated with fewer tender joints (p=0.05) and higher ESR (p=0.02) at baseline. Conclusions Excellent radiographic outcome was achieved for patients treated according to a protocolled T2T strategy in daily clinical practice. Patients treated with initial monotherapy had significantly more short-term radiographic progression than patients treated with initial combination therapy. References Steunebrink LMM, Vonkeman HE, ten Klooster PM, et al. (2016) Recently diagnosed rheumatoid arthritis patients benefit from a treat-to-target strategy: results from the DREAM registry. Clin Rheumatol 35:609–615. doi: 10.1007/s10067–016–3191–3. Steunebrink LMM, Versteeg GA, Vonkeman HE, et al. (2015) Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry. Arthritis Res Ther 18:60. doi: 10.1186/s13075–016–0962–9. Stenger AA, Van Leeuwen MA, Houtman PM, et al. (1998) Early effective suppression of inflammation in rheumatoid arthritis reduces radiographic progression. Br J Rheumatol 37:1157–63. Goekoop-Ruiterman YPM, de Vries-Bouwstra JK, Allaart CF, et al. (2008) Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): A randomized, controlled trial. Arthritis Rheum 58:S126–35. doi: 10.1002/art.23364. Acknowledgements We would like to thank all the patients, rheumatology nurses, and rheumatologists who participated in our study. Disclosure of Interest None declared

SAT0157 Randomized Trial of Stopping TNF-Inhibitors in Rheumatoid Arthritis Patients with Stable Remission or Low Disease Activity in the Netherlands

Background The effectiveness of TNF-inhibitors (TNFi) in the treatment of rheumatoid arthritis has been demonstrated in many studies [1]. However, little is known on stopping TNFi in patients with stable low disease activity and the subsequent likelihood of exacerbation of rheumatoid arthritis (RA). In addition, it is not clear whether TNFi can be restarted effectively and safely. Given the costs and risks [2], it is important to examine whether patients in stable low disease activity can effectively stop TNFi. Objectives To assess whether RA-patients in stable remission or low disease activity (DAS28<3.2) can effectively and safely stop and restart TNFi. Methods Multicenter open-label randomized controlled trial. Patients diagnosed with RA according to the ACR 1987 criteria were included. Patients had been treated with a TNFi for at least 1 year and with stable dose DMARDs for at least 6 months. All included patients had low disease activity in the 6 months prior to inclusion, with at least 2 DAS28 scores <3.2 in this period. Patients were randomized to stop or continue their current TNFi in a 2:1 ratio. DAS28 flare was defined as DAS28 ≥3.2 with an increase ≥0.6 compared to the previous DAS28. Results In total 817 patients from 47 centers were included: 531 (65%) patients were randomized to the stop group and 286 (35%) to TNFi continuation. All included patients had low disease activity in the 6 months prior to inclusion, with at least 2 DAS28 scores <3.2 in this period and 81.1% was in remission (DAS28<2.6). At 6 months, significantly more patients in the stop group had experienced a DAS28 flare versus the continuation group (29.3% vs 9.7% respectively, p<0.0001). At 12 months these were 40.8% vs 14.4% respectively, p<0.0001. Flare free survival was significantly lower in the stop group (p<0.0001), with a median time to first flare of 24 weeks in those that flared. The adjusted hazard ratio for flare after stopping TNFi was 3.19 (95% CI: 2.26–4.50). Of the patients that restarted TNFi within the first 26 weeks after stopping, already 83% had regained DAS28<3.2 six months later and median survival time to regained DAS28<3.2 was 12 weeks (95% Cl 10.9-13.1). Conclusions 59% of RA-patients with stable remission or low disease activity (DAS28 <3.2) can stop TNFi without flare in 12 months follow up. The data suggest that TNFi can be restarted effectively and safely. References Nam JL, Winthrop KL, van Vollenhoven RF, et al. Current evidence for the management of rheumatoid arthritis with biological disease-modifying antirheumatic drugs: a systematic literature review informing the EULAR recommendations for the management of RA. Ann Rheum Dis 2010;69:976–86. Ramiro S, Gaujoux-Viala C, Nam JL, et al. Safety of synthetic and biological DMARDs – a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2013; submitted. Disclosure of Interest None declared

THU0111 Prevalence and Cross-Sectional Associations of Neuropathic-Like Pain Features in Rheumatoid Arthritis

Background Pain control in rheumatoid arthritis (RA) is often inadequate and clinically significant pain persists in a substantial proportion of patients, even when inflammation appears to be well controlled. This suggests that inflammation or subsequent joint damage might not be the only factor causing pain in RA. Accumulating evidence suggests that features of neuropathic pain may also be present in patients with rheumatic pain conditions. Objectives To estimate the prevalence and factors associated with neuropathic-like pain symptoms in patients with rheumatoid arthritis (RA). Methods A cross-sectional sample of 159 RA patients completed the painDETECT questionnaire along with other self-reported measures before their visit to the rheumatology outpatient clinic. Univariate analyses and multivariable logistic regression were used to identify factors associated with neuropathic pain features. Results The large majority of patients (88%) were in remission or had low disease activity, but 44% of the patients continued to report clinically significant pain. According to the painDETECT, 27 patients (17.0%) were classified as having likely neuropathic pain and 34 patients (21.4%) as having possible neuropathic pain. Besides reporting more intense pain, patients with likely or possible neuropathic pain were more likely to meet the diagnostic criteria for fibromyalgia, to use analgesics, and to have more tender joints and worse physical and mental health status as measured by the SF-36. In multivariable analysis, physical (P<0.001) and mental health status (P=0.006) remained significantly associated with neuropathic pain features, even after controlling for pain severity. Conclusions Neuropathic-like pain symptoms are present in a substantial number of patients with RA and are associated with worse physical and mental health. These symptoms may represent central sensitization and underscore the need for further research and screening of pain mechanisms in RA patients. Disclosure of Interest None declared

THU0118 General Applicability of a New Treat-to-Target Treatment Strategy in Dutch Patients with Early Rheumatoid Arthritis: Results from the Dream Remission induction Cohort II

Background New treatment options and strategies have dramatically reduced the severity and impact of rheumatoid arthritis (RA) and especially early intensive combination therapy, aimed at achieving remission, has shown good clinical outcomes. The reason for early identification and treatment of RA is to control progression of the disease. Since there is no cure for RA, the current most important goal is to reach remission as soon as possible, which should be sustained during the course of the disease. Objectives Despite wide implementation of treat-to-target (T2T) strategies in RA, a proportion of patients still fail to achieve early remission. This study aimed to identify baseline predictors of reaching remission in Dutch patients with early RA following a T2T strategy. Methods Baseline demographic, clinical and patient-reported outcome measures and one-year follow-up data were used from patients with early RA included in the DREAM remission induction cohort II study. Survival analyses and simple and multivariable logistic regression analyses were used to examine remission rates and significant predictors of achieving remission. Results A total number of 137 patients was included. 77.2% of the patients reached remission at least once in 12 months follow-up, and median time to first remission was 17 weeks. None of the examined baseline variables were significantly associated with achieving remission within 1 year. Lower ESR (p=0.007), male gender (p=0.057), better physical health status (p=0.062) and fewer tender joints (p=0.175) were significantly or marginally associated with achieving remission within 17 weeks. In multivariable analysis, however, only ESR remained significantly predictive (p=0.023). Conclusions The results indicate that baseline characteristics were not predictive of early remission. Together with the high proportion of responders, this provides additional evidence for the general applicability of T2T strategies in patients with early RA. Disclosure of Interest None declared

FRI0017 How Age, Gender and Body Mass Index Affect the Erythrocyte Sedimentation Rate and the C-Reactive Protein in Early Rheumatoid Arthritis

Background The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are two commonly used indirect measures of the extent of inflammation in rheumatoid arthritis (RA). As current RA treatment guidelines strongly emphasize early and aggressive treatment aiming at fast remission, optimal measurement of inflammation in this patient group is becoming increasingly important (Combe et al., 2007; Smolen et al., 2010). However, although dependencies with age, gender, and body mass index have been shown for both inflammatory markers, it remains unclear which inflammatory marker is least affected by these effects in patients with early rheumatoid arthritis. Objectives To determine which inflammatory marker, the ESR or CRP, is least affected by age, gender, and BMI in patients with early RA. Methods Baseline data from 589 patients from the DREAM registry were used for analyses. Associations between the inflammatory markers and age, gender, and BMI were evaluated first using univariate linear regression analyses. Next, it was tested whether these associations were independent of a patients current disease activity (as measured with the other core components of the DAS28) as well as of each other using multiple linear regression analyses with backward elimination. The strengths of the associations were compared using standardized beta (β) coefficients. Results Both ESR and CRP were univariately associated with age, gender, and BMI, although the association with BMI disappeared in multivariate analyses. ESR and CRP concentrations significantly increased with age (β-ESR=0.017, p<0.001 and β-CRP=0.009, p=0.006), independently of the number of tender and swollen joints, patient-reported wellbeing, and gender. Furthermore, women demonstrated average ESR levels that were significantly higher than that of men (β=0.198, p=0.007), whereas men had higher CRP levels (β=-0.182, p=0.048). The effects were shown to be strongest on the ESR. Conclusions Age and gender are independently associated with the concentrations of both acute phase reactants in early RA, emphasizing the need to take these external factors into account when interpreting disease activity measures. References Combe B, Landewe R, Lukas C, Bolosiu HD, Breedveld F, Dougados M, et al. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66(1):34-45. Smolen JS, Aletaha D, Bijlsma JW, Breedveld FC, Boumpas D, Burmester G, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69(4):631-7. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5202