Background/Purpose

The introduction of DAS-driven intensive treatment strategies in early rheumatoid arthritis (RA) has considerably improved outcome and patients’ quality of life. Previous studies have also suggested the possibility, in selected cases, of maintenance of an acceptable clinical status for prolonged periods following treatment suspension. Despite these observations, three critical issues remain partly unsolved: 1) whether systemic suppression of inflammation can coincide with reversal of the pathogenic process, 2) the possibility to define exploitable parameters able to predict in which patients treatment can be suspended, 3) the primary dynamics as well as the anatomic-biologic substrate of relapse. The aim of the current study was to investigate the clinical-radiographic-functional outcome and ultrasonographic-synovitis dynamics of RA patients in DMARDs-induced SDAI remission, during 12 months drug-free follow-up.

Methods

From December 2011, all RA patients followed at our Early Arthritis Clinic achieving stable clinical remission and candidate to treatment suspension are referred to a dedicated Remission Clinic. Referral criteria: 1) introduction of DMARDs treatment within 12 months from symptoms’ onset, 2) ≥24 months DMARDs treatment with a DAS28-driven intensive protocol, 3) stable DAS28 remission (DAS28<2.6) for at least 6 months in the absence of corticosteroids. All patients allowed to drug-free follow-up are monitored at three months’ intervals through complete clinical, ultrasonographic (hands-feet-axillary lymph nodes’ PD-US) and immunologic screenings. Hands-feet radiographs are performed at baseline and every 12 months. Treatment is re-introduced in case of moderate disease activity (DAS28>3.2) or radiographic progression.

Results

40 consecutive RA patients in DAS28 and SDAI remission (SDAI≤3.3) at the baseline visit have been followed-up for 12 months in drug-free regimen and monitored every 3 months. Maintenance of stable DAS28 remission (T0-T12) was observed in 18/40 patients (45%), while treatment re-introduction due to disease relapse was required in 13/40 patients (32.5%). No significant radiographic progression (SHS) and functional impairment (HAQ) was detected at a group level during drug-free follow-up. Ultrasonographic stratification at baseline showed the absence of power Doppler signal (hands-wrists) in 29/40 (72.5%) (SDAI≤3.3-PD=0). Despite stringent remission and absence of sub-clinical signs of synovitis at recruitment, 8/29 (27.5%) patients relapsed, while in 12/21 (57.1%) a transient or persistent reappearance of defined PD signal (PD>1) was detected during follow-up despite the lack of requirement of DMARDs re-introduction according to study criteria.

Conclusion

Suspension of DMARDs with short term maintenance of good clinical status is an achievable goal after treat-to-target and tight control strategies in early RA. However, despite stringent clinical and ultrasonographic remission, relapse or signs of disease reactivation can occur early after drug withdrawal, supporting the requirement of additional patho-biologic insights for a more specific stratification of RA remission phase.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/from-early-arthritis-clinic-to-remission-clinic-short-term-outcome-and-ultrasonographic-synovitis-dynamics-in-rheumatoid-arthritis-patients-in-dmard-induced-sdai-remission-during-drug-free-follow-up/