medwireNews: In patients with anti-cyclic citrullinated protein antibody (ACPA)-negative rheumatoid arthritis (RA), research suggests that an early response to treatment increases the likelihood of reaching sustained DMARD-free remission (SDFR).
“The notion that an early response to treatment is important for this long-term outcome suggests that timely reduction of inflammation might confine chronification in RA,” say Marloes Verstappen (Leiden University Medical Center, the Netherlands) and colleagues.
They explain that the ability to predict which patients are likely to achieve SDFR “can be important for clinicians, as it can contribute to the selection of RA patients eligible for DMARD discontinuation.”
The findings were based on data for 772 patients at the Leiden Early Arthritis Clinic who were diagnosed with RA between 1999 and 2014 and started on a conventional synthetic (cs)DMARD.
During the 7 years of follow-up, 19.3% achieved SDFR, defined as the absence of synovitis for at least 12 months after stopping DMARD treatment. The median time to SDFR was 3.2 years. Among the remaining 80.7% of patients, 24 achieved SDFR only after the 7-year cutoff (median 9.6 years), 588 failed to achieve SDFR, and 11 experienced a flare a median 2.6 years after achieving SDFR.
After 4 months of treatment, the patients in the SDFR group had a significantly greater average decline in clinical disease activity, as measured by DAS, than those not achieving SDFR, at 1.59 versus 0.96 units.
The same pattern was seen among the 51.8% of ACPA-negative patients, who accounted for 85.2% of the patients who achieved SDFR. Among this group, the rate of DAS decline after 4 months was an average 1.73 units for those who achieved SDFR, which was significantly greater than the 1.07 units for those who did not.
The decline in DAS scores did not significantly differ between ACPA-positive patients who did and did not achieve SDFR, however, the researchers note that the small number of ACPA-positive patients achieving SDFR (4.3%) may have limited the power to detect any between-group differences.
In multivariable analysis of ACPA-negative patients, not only did the decline in DAS within 4 months of treatment significantly predict SDFR at 7 years, but also the absolute DAS at 4 months, which the researchers say is “more practical for use in clinical practice than a DAS change over time.”
Of the ACPA-negative patients whose DAS was 1.5 points or lower at month 4, 70.2% achieved remission, whereas only 7.1% of those who had a score of 3.6 points or higher reached SDFR.
“The optimal moment for evaluation of an early treatment response remains to be determined,” explain the study investigators in Arthritis Research & Therapy.
They conclude: “Currently, treatment and tapering strategies are formally similar for ACPA-positive and ACPA-negative RA patients, and discontinuation of treatment is based on trial and error. Our findings might aid to construct more substantiated discontinuation strategies, stratified for ACPA status.”
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Arthritis Res Ther 2020; doi:10.1186/s13075-020-02368-9