Background/Purpose: Rheumatoid arthritis (RA) treatment emphasizes aggressive titration of disease-modifying antirheumatic drugs (DMARDs) with the goal of achieving disease remission. This often includes the use of multiple DMARDs in combination, which can have a significant impact on patients’ lives and add costs to the healthcare system. The primary objective of our study was to describe the patterns of sustained remission and subsequent treatment reduction in the usual clinical practice for patients with early RA. Furthermore, we wished to assess for an effect of tapering medications on the risk of disease flare.

Methods: Patients (age >18) enrolled in the Canadian early ArThritis CoHort (CATCH) between January 2007 to March 2017 were analyzed. CATCH is a prospective, observational study of patients with early inflammatory arthritis (symptoms < 1 year) treated in rheumatology clinics across Canada. The analysis cohort included patients with a diagnosis of RA according to the 1987 or 2010 ACR/EULAR classification criteria, active disease at enrolment (DAS28 >2.6) and those treated with at least one DMARD or biologic agent within the first three months of study enrolment. We defined sustained remission as achieving a DAS28 < 2.6 at two consecutive follow-up visits at least six months apart. Reduction of therapy was defined as a minimum of a 25% dose reduction of conventional synthetic, targeted, or biologic DMARDs. Descriptive statistics were used to summarize the time to remission and reductions in DMARD therapy. Logistic regression analysis was used to assess predictors of sustained remission. 

Results: Eight hundred and thirty-seven (40%) of the 2,097 eligible patients achieved sustained remission during the study period. Of these, 60% did so within the first 18 months and 92% within the first four years (Figure 1).  The mean (SD) baseline DAS28 was 5.1 (1.3), and HAQ-DI was 1.0 (0.7). At the time of remission, 80% were prescribed methotrexate (55% subcutaneously), 71% were prescribed combination therapy with other conventional synthetic DMARDs, and 13% were prescribed a biologic agent. In the year after attaining sustained remission, 327 (39%) patients reduced treatment in the following pattern (patients may have had more than one change): 250 patients reduced or stopped methotrexate, 196 patients reduced or stopped non-methotrexate DMARDs, and 34 patients reduced or stopped biologic agents. For those that reduced or stopped a biologic, only one patient did so due to side effects. Of the 250 patients who reduced or stopped methotrexate, 25 were for a side effect. Of the 636 patients with outcome data available, 54% remained in sustained remission 12-18 months after first achieving it. This was not associated with tapering DMARDs [odds ratio (95% confidence interval) tapering versus not tapering: 0.96 (0.66 – 1.41)].

Conclusion: Achieving sustained remission occurred in 40% of early RA patients in usual clinical practice. Treatment reductions following sustained remission occurred in over a third of patients over the next 12 months and consisted mainly of adjustment in non-biologic DMARDs. Further study is required to determine whether or not medications can be tapered safely without disease flare.

TIme to remission 2

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/patterns-of-sustained-remission-and-subsequent-dmard-tapering-in-early-rheumatoid-arthritis-data-from-the-canadian-early-arthritis-cohort/