Background/Purpose:

Recently, it is recommended that tapering csDMARDs could be considered If a patient is in persistent remission. However, the methods of tapering csDMARDs including MTX without RA flare is not established. In this study, we determine whether half dose redaction of MTX in RA patient who achieved clinical remission is possible without flare by using clinical disease activity and MRI images of hand.

Methods:

Out patient of department of Rheumatology on our hospital were included in this study. Inclusion criteria was the following: diagnosis of RA was based on 2010 ACR/EULAR classification criteria; achieving clinical remission defined by DAS28-CRP over 4 weeks; been treated with methotrexate and was reduced by half according to the patient wishes; MRI images of hand was available at reduction of MTX. The exclusion criteria were as follows: been treated leflunomide or tacrolimus, tsDMARDs and bDMARDs; oral prednisolone more than 5mg/day. In this study, disease flare was defined as DAS28-CRP of ≥2.3 at two sequential visits, dose increase of MTX and add-on other DMARDs. MRIs of the patient’s dominant wrist and 2nd–5th metacarpophalangeal (MCP) joints were obtained using 1.5 T whole-body MRI unit (Achieva 1.5T, Philips Healthcare, Best, The Netherlands) with contrast enhancement. The MR image sets were assessed for bone erosions, synovitis and bone marrow edema according to the original OMERACT RAMRIS.

Results:

Fifteen patients were enrolled in this study (10 female). The mean (±SD) age, disease duration, MTX dose before reduced and DAS28-CRP at baseline was 66.6 ± 9.8y, 6.0 ± 3.6y, 8.8 ± 3.4mg/w and 1.32 ± 0.26. Thirteen patients were positive for anti-CCP antibody and RF. Subclinical MRI inflammation was detected in all patients. The median(range) synovitis, bone edema and bone erosion sore were 2(0-7), 0(0-4) and 7(1-22). Two patients experienced disease flare at week 16 and these patients had significantly higher MRI synovitis score (4.5 vs. 1.9 p < 0.05). Higher score of DAS28-CRP at baseline independently predicted higher MRI synovitis score (β = 4.454, 95% CI 0.930-7.988, p<0.05). Analysis of the ROC curve identified the most sensitive and specific cut-off value for MRI synovitis score to be 5 (AUC = 0.923, 95% CI 0.077-1.000, p<0.05).

Conclusion:

Baseline DAS28-CRP could predict baseline MRI synovitis score. However, even if in clinical remission, it is reported subclinical remission would remain and depending on degree of it, radiographic progression can progress. Hence, not only clinical evaluation but also MRI evaluation is important before reduction of DMARDs. We conclude that half dose redaction of MTX for the RA patient who achieved clinical remission and had low grade MRI synovitis score might be a beneficial option of tapering MTX.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/half-dose-reduction-of-methotrexate-in-patient-with-ra-who-achieved-clinical-remission/