title: Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission.
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.
authors.affiliation: King's College, London, UK. drelmiedany@rheumatology4u.com.|Rheumatology & Rehab, Ain Shams University, Cairo, Egypt. drelmiedany@rheumatology4u.com.|Darent Valley Hospital, Dartford, Kent, DA2 8DA, UK. drelmiedany@rheumatology4u.com.
authors.forename: Y
authors.initials: Y
authors.lastname: El Miedany
authors.affiliation: Community and Public Health, Ain Shams University, Cairo, Egypt.
authors.forename: M
authors.initials: M
authors.lastname: El Gaafary
authors.affiliation: Rheumatology & Rehab, Ain Shams University, Cairo, Egypt.
authors.forename: S
authors.initials: S
authors.lastname: Youssef
authors.affiliation: Internal Medicine, Cairo University, Cairo, Egypt.
authors.forename: I
authors.initials: I
authors.lastname: Ahmed
authors.affiliation: Rheumatology, King Abdel Aziz University, Jeddah, Saudi Arabia.
authors.forename: Sami
authors.initials: S
authors.lastname: Bahlas
authors.affiliation: Medicine, Al Adan Hospital, Kuwait, Kuwait.
authors.forename: M
authors.initials: M
authors.lastname: Hegazi
authors.affiliation: Radiology Department, Ain Shams Univerity, Cairo, Egypt.
authors.forename: A
authors.initials: A
authors.lastname: Nasr
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D001323:Autoantibodies / Q000097:blood; D001688:Biological Products / Q000627:therapeutic use*; D018450:Disease Progression; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007249:Inflammation / Q000000981:diagnostic imaging / Q000188:drug therapy*; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012372:ROC Curve; D012008:Recurrence; D012074:Remission Induction; D012219:Rheumatology; D013585:Synovitis / Q000188:drug therapy; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D018501:Antirheumatic Agents; D001323:Autoantibodies; D001688:Biological Products; D008727:Methotrexate
keywords: Early arthritis; Joint; Remission; US