Abstract
ObjectivesTo study the impact of treatment strategy on achieving and sustaining disease-modifying antirheumatic drug (DMARD)-free remission in patients with rheumatoid arthritis (RA).MethodsTwo hundred seventy-nine RA patients (median follow-up 7.8 years) were studied. Of these, 155 patients participated in a disease activity score (DAS) < 1.6 steered trial aimed at DMARD-free remission. Initial treatment comprised methotrexate with high-dose prednisone (60 mg/day) and a possibility to start biologicals after 4 months. In the same period and hospital, 124 patients were treated according to routine care, comprising DAS < 2.4 steered treatment. Percentages of DMARD-free remission (absence of synovitis for ≥ 1 year after DMARD cessation), late flares (recurrence of clinical synovitis ≥ 1 year after DMARD cessation), and DMARD-free sustained remission (DMARD-free remission sustained during complete follow-up) were compared between both treatment strategies.ResultsPatients receiving intensive treatment were younger and more often ACPA-positive. On a group level, there was no significant association between intensive treatment and DMARD-free remission (35% vs 29%, corrected hazard ratio (HR) 1.4, 95%CI 0.9–2.2), nor in ACPA-negative RA (49% versus 44%). In ACPA-positive RA intensive treatment resulted in more DMARD-free remission (25% vs 6%, corrected HR 4.9, 95%CI 1.4–17). Intensive treatment was associated with more late flares (20% versus 8%, HR 2.3, 95%CI 0.6–8.3). Subsequently, there was no difference in DMARD-free sustained remission on a group level (28% versus 27%), nor in the ACPA-negative (43% versus 42%) or ACPA-positive stratum (17% versus 6%, corrected HR 3.1, 95%CI 0.9–11).ConclusionsIntensive treatment did not result in more DMARD-free sustained remission, compared to routine up-to-date care. The data showed a tendency towards an effect of intensive treatment in ACPA-positive RA; this needs further investigation.
Highlights
Over the last decades, treatment of rheumatoid arthritis (RA) has changed dramatically
disease-modifying antirheumatic drug (DMARD)-free sustained remission, which has been defined as the sustained absence of arthritis after cessation of DMARDs, may be interpreted as the closest proxy to cure of RA, especially as it corresponds with a patient-perceived state of remission in terms of normalized levels of physical functioning, pain, fatigue, and stiffness [13, 14]
Studies have shown it is an achievable goal in part of RA patients, European League Against Rheumatism (EULAR) recommendations are cautious with regard to tapering and stopping DMARDs
Summary
Treatment of rheumatoid arthritis (RA) has changed dramatically. The recent European League Against Rheumatism (EULAR) recommendations for the management of RA state that treatment should be aimed at sustained remission or low disease activity, defined according to Boolean or index-based definitions, which correspond with the absence of radiologic damage [2, 4]. These treatment aims can be achieved while patients are still on disease-modifying antirheumatic drugs (DMARDs). The main reason for this being the lack of evidence about safely stopping DMARD therapy and the risk of flares [2, 15,16,17]
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