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Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission

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Abstract

This study aims to assess clinical, lab/immunological or imaging (joint ultrasonography) markers able to predict disease relapse in RA patients in sustained remission when tapering or stopping their treatment. One hundred fifty-seven RA patients in clinical remission (DAS-28 <2.6 for >6 months), receiving treatment with sDMARDs and bDMARD therapy, were randomly allocated into any of five groups: Group 1: continue full dose DMARDs and taper biologic therapy by 50 % (31 patients); Group 2: taper both DMARDs and biologic therapy dose by 50 % (32 patients); Group 3: taper DMARDs by 50 % and stop biologic therapy (31 patients); Group 4: stop both DMARDs and biologic therapy (31 patients); Group 5: continue medications without change (31 patients). Forty joints were assessed ultrasonographically (DAS-28 joints + ankles + metatarsophalangeal joints) and prospectively monitored for 12 months. The primary endpoint was sustained remission for 12 months. Patients were considered as having a relapse when the DAS-28 score was >3.2 and anti-rheumatic treatment was escalated. The frequency of relapse was 41.9 % in Group 1, 59.3 % in Group 2, 67.7 % in Group 3, 77.4 % in Group 4 and 6.5 % in Group 5. Relapse rates were significantly higher in patients whose ultrasound scores raised within 3 months of stopping their medications (P < 0.001 for both GS and PD scores). Cox regression identified ACPA positivity (at baseline) and progression of functional disability (at 2 months) as predictors for relapse. Tapering therapy is feasible in RA patients. Tailored dynamic approach is advised. Joint ultrasonographic assessment, ACPA positivity and worsening functional disability predicted relapse within a short term after discontinuation of the treatment. RA patients whose DAS-28 score was <2 were more likely to remain in remission.

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Acknowledgments

We express thanks to all participants, our colleagues, research assistants and nurses for their cooperation and help to bring this research to its final conclusions.

Contributorship

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. El Miedany had full access to all of the data in the study, and Dr. El Gaafary carried out the data analysis.

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Authors and Affiliations

  1. King’s College, London, UK

    Y. El Miedany

  2. Rheumatology & Rehab, Ain Shams University, Cairo, Egypt

    Y. El Miedany & S. Youssef

  3. Darent Valley Hospital, Dartford, Kent, DA2 8DA, UK

    Y. El Miedany

  4. Community and Public Health, Ain Shams University, Cairo, Egypt

    M. El Gaafary

  5. Internal Medicine, Cairo University, Cairo, Egypt

    I. Ahmed

  6. Rheumatology, King Abdel Aziz University, Jeddah, Saudi Arabia

    Sami Bahlas

  7. Medicine, Al Adan Hospital, Kuwait, Kuwait

    M. Hegazi

  8. Radiology Department, Ain Shams Univerity, Cairo, Egypt

    A. Nasr

Authors
  1. Y. El Miedany
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  3. S. Youssef
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  4. I. Ahmed
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Correspondence to Y. El Miedany.

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Ain Shams University Research Ethics Board.

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El Miedany, Y., El Gaafary, M., Youssef, S. et al. Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission. Clin Rheumatol 35, 2915–2923 (2016). https://doi.org/10.1007/s10067-016-3413-8

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  • DOI: https://doi.org/10.1007/s10067-016-3413-8

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