Zusammenfassung
Die Qualität heutiger Behandlungsmöglichkeiten für die rheumatoide Arthritis (RA) hat zu hochgesteckten Therapiezielen wie Remission geführt, die in vielen Fällen auch erreicht werden. Patientenwünschen entsprechend, aber auch aus ökonomischen Gründen wird vermehrt die Möglichkeit diskutiert, nach Erreichen des Therapieziels die Behandlung zu reduzieren und letztlich sogar versuchsweise abzusetzen („drug-free remission“). Zunehmend zeigen Studienergebnisse, dass in etwa 30–60 % der Fälle ein solches Vorgehen zumindest für einige Zeit erfolgreich ist. Da erneute Therapie im Fall eines Flare fast immer gelingt, ist das Risiko eines solchen Vorgehens gering – sofern eine Überwachung des Patienten nach Reduktion bzw. Absetzen sicher gewährleistet ist. Bisher gibt es keine Belege dafür, dass die Strategie des kontrollierten Therapieabbaus ein Risiko für ungünstige Langzeitfolgen beinhaltet. Als Reihenfolge für das Vorgehen empfehlen gegenwärtig die Leitlinien, zuerst das Glukokortikoid abzusetzen, anschließend das Biologikum zu reduzieren, ggf. später abzusetzen, schließlich bei anhaltender Remission ähnlich mit dem synthetischen DMARD („disease modifying antirheumatic drug“; in der Regel Methotrexat) zu verfahren. Eine Reihe von Voraussetzungen scheint den Erfolg der Therapiereduktion zu begünstigen wie eher niedrige Krankheitsaktivität zu Beginn, Seronegativität sowie insbesondere kurze Krankheitsdauer bei Therapiebeginn. Die Entscheidung zum Abbau muss von Arzt und Patient gemeinsam getroffen werden, eine stabile Einstellung der RA sollte mindestens seit 6 Monaten bestehen.
Abstract
Nowadays, the excellent treatment options available for rheumatoid arthritis (RA) result in ambitious therapeutic goals, such as remission, which can actually be achieved for many RA patients. In a state of sustained remission many patients request reduction in drug treatment and this as well as economic reasons makes treatment reduction or even drug-free remission a reasonable target. Increasingly successful reduction of disease-modifying antirheumatic drug (DMARD) treatment has been shown in studies for approximately 30–60 % of patients in sustained remission, at least for some period of time. Because flare retreatment is successful in nearly all cases, the risk of treatment de-escalation can be minimized, so long as patients are continuously monitored after reduction or termination of drug treatment. No study has yet shown an elevated risk for unfavorable long-term outcome in cases of controlled treatment reduction. Current treatment recommendations are that glucocorticoids should first be withdrawn followed by reduction and termination of biologics and in cases of sustained remission finally, conventional DMARDs, such as methotrexate should be reduced and possibly terminated to achieve the defined target of drug-free remission. Factors facilitating success of tapering antirheumatic drugs are low disease activity at initiation, negative serological tests and short disease duration after starting DMARD treatment. A joint decision between rheumatologists and patients as well as continuous remission for at least 6 months are prerequisites for drug reduction.
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Interessenkonflikt. K. Krüger: Vorträge und Beratungstätigkeit für die Firmen Abbvie, BMS, Medac, MSD, Pfizer, Roche, UCB. E. Edelmann: Vorträge und Beratungstätigkeit für die Firmen Abbvie, BMS, MSD, Pfizer, Roche/Chugai, UCB.
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Krüger, K., Edelmann, E. Therapieabbau bei stabil eingestellter rheumatoider Arthritis. Z Rheumatol 74, 414–420 (2015). https://doi.org/10.1007/s00393-014-1534-5
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DOI: https://doi.org/10.1007/s00393-014-1534-5