Sustained biologic-free and drug-free remission in rheumatoid arthritis, where are we now?

György Nagy,Ronald F Van Vollenhoven

doi:10.1186/s13075-015-0707-1

Abstract

The advent of new medications and new treatment strategies for rheumatoid arthritis has made it possible to achieve remission in more patients than before. Furthermore, recent clinical trials and register studies suggest that some patients who initially required aggressive therapy may achieve biologic-free remission or even the ultimate goal of therapy, drug-free remission, resembling recovery. Here, we present a discursive review of the most important studies addressing these issues. Based on the overall results, it remains unclear if achieving biologic-free and drug-free remissions are primarily due to the natural course of the disease or to the early therapeutic intervention according to the ‘window of opportunity’ hypothesis. Although medication-free remission is only achievable in a small subset of patients, characterizing this patient cohort may provide important information about beneficial prognostic factors and the underlying mechanisms. In summary, in a subset of patients biologic-free and even drug-free remission can be achieved; pursuing these possibilities in practice may decrease the risk for long-term side effects and attenuate the economic burden of the disease.

Highlights

Control of inflammation in rheumatoid arthritis (RA) generally results in better outcomes; the current treatment strategy is to initiate aggressive therapy as soon as possible after diagnosis has been established, and to extend the therapy, according to the disease activity, to reachParadoxically, we know much more about optimal initiation than about optimal termination of pharmacotherapy in RA [3]
A small but not inconsiderable proportion of patients with RA may have a chance for drug-free remission, which might be due to the natural course of the disease and/or to the therapies used; the key question is whether currently available medications may alter this chance [4]
From week 26, in the unblinded, open label phase of the study patients with an inadequate response (DAS44 > 2.4) in the infliximab group were treated with increased infliximab doses, or biological therapy was stopped and MTX was changed to other synthetic disease modifying antirheumatic drug (sDMARD)

Summary

Introduction

Control of inflammation in rheumatoid arthritis (RA) generally results in better outcomes; the current treatment strategy is to initiate aggressive therapy as soon as possible after diagnosis has been established, and to extend the therapy, according to the disease activity, to reachParadoxically, we know much more about optimal initiation than about optimal termination of pharmacotherapy in RA [3]. Remission induction and tapering biologicals According to the concept of the ‘window of opportunity’ [14,15,16], aggressive treatment in the early phase of the disease may lead to excellent improvement and sustained benefit (Fig. 1).

Results

Conclusion