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DMARD-Free Remission Feasible for bDMARD-Naive Patients for RA
Around 37% of those had never used a bDMARD reached sustained DMARD-free remission at 5 years,
New research on which patients with rheumatoid arthritis (RA) can attain disease-modifying antirheumatic drug (DMARD)-free remission has called into question current European Alliance of Associations for Rheumatology (EULAR) recommendations to continue DMARD use through remission.1
The new research, published in Lancet Rheumatology, was led by Judith W. Heutz, MD, Department of Rheumatology, Erasmus Medical Center, Netherlands. Heutz and colleagues drew on data from the Leiden Early Arthritis Clinic (EAC) and the treatment in the Rotterdam Early Arthritis Cohort (tREACH), a treat-to-target steered trial in which biological DMARDs were started when patients had inadequate response to triple DMARD-therapy (methotrexate, sulfasalazine, and hydroxychloroquine), for the study.
“This [study] means that this advanced goal of remaining in a good health status in regard to RA, which should be imminent in the definition of remission, but without the risks associated with DMARD use, is attainable by a considerable proportion of patients with rheumatoid arthritis who do not use biological DMARDs,” Paul Studenic, PhD, Division of Rheumatology of the Medical University of Vienna, wrote in a related editorial.2
Heutz and colleagues included 627 patients from the EAC, 391 (62%) of which were female and 236 (38%) of which were male. Participants had a mean age of 60 years (standard deviation [SD], 14) and 502 (95%) of 529 patients who reported were White. Most (n = 538; 86%) had never used a biological DMARD. All ofthe minority who had used a biological DMARD did not reach sustained DMARD-free remission, whereas 37% of the patients who never used a biological DMARD reached sustained DMARD-free remission at 5 years (hazard ratio [HR], 0.02 [95% CI, 0·00–0·10]; P <·0001).1
There were 425 patients included from the tREACH population, 286 (67%) patients were female, and the mean age was 54 years (SD, 14). Most (n = 271; 64%) had never used a biological DMARD. Similarly to the EAC cohort, none of the patients that used a biological DMARD reached sustained DMARD-free remission, whereas 15% of patients who never used a biological DMARD reached sustained DMARD-free remission at 3 years (HR, 0·03 [95% CI, 0·00–0·21]; P <·0001).1
“This study adds to the evidence on managing patients in remission and serves to reflect on how to discuss treatment or withdrawal decisions when weighing the risks of disease worsening or progression versus potential treatment related complications. The EULAR recommendations for managing rheumatoid arthritis have emphasized the tapering aspect of DMARDs without explicitly stating a recommendation for complete cessation; however, there have been incremental discussions on complete cessation since the 2016 update,” Studenic wrote.2
Heutz and colleagues noted that 90% of the patients that reached sustained DMARD-free remission did not flare during their follow-up and maintained sustained DMARD-free remission for a median of 3 to 4 years until follow-up ended.1
In terms of study limitations, the investigators did note that although they adjusted for ACPA-status, they did not correct for other factors, such as disease activity, leading to possible residual confounding, however, this was not done because exposure to biological DMARDs is connected to disease activity. They also noted relatively wide confidence intervals of hazard ratios, due to the small effective sample size, as well as having lost some participants to follow-up in tREACH after 3 years.
