Sustained remission after cessation of disease-modifying antirheumatic drugs (DMARDs) is achievable in approximately 10% to 20% of patients with rheumatoid arthritis (RA), according to study results published in RMD Open.
Researchers from the Netherlands performed a systematic literature review of 14 clinical trials and 5 observational studies that reported on DMARD discontinuation in patients with RA who achieved remission. The prevalence of DMARD-free remission and its sustainability were identified across studies. In addition, the researchers assessed disease flares during tapering and following DMARD cessation. Potential predictors for DMARD-free remission were also assessed in the included studies.
Across studies, the definitions of DMARD-free remission varied, particularly with regard to the duration of the DMARD-free state. Remission criterion, most often the Disease Activity Score in 44 joints (DAS44) and 28 joints (DAS28) definition for remission, were typically used to define DMARD-free remission. The reported prevalence of DMARD-free remission in 5 high-quality trials ranged between 5.0% and 24.3%. A similar DMARD-free remission range was reported in 2 moderate-quality studies (5.9%-21.9%). Overall, DMARD-free remission was sustained in 11.6% to 19.4% of patients, but only 2 trials contributed data on sustained remission of >12 months.
Between 41.8% and 75.0% of patients experienced flares during DMARD tapering. Flares were also reported in 10.4% to 11.8% of patients in the first year after DMARD-free remission was achieved. Late flares, or flares that occurred >1 year after stopping DMARDs, occurred in only 0.3% to 3.5% of cases. Patient-level factors associated with the chance of DMARD-free remission achievement included the lack of autoantibodies and HLA-shared epitope alleles.
Limitations of this study were the lack of a meta-analysis given substantial heterogeneity in the studies, the inclusion of only a small number of studies, and the researchers’ inability to determine how long remission should be sustained before DMARDs are tapered.
The researchers of this review study added that “DMARD-free remission can become an important outcome measure for clinical trials, though this requires consistency in the definition. We propose to incorporate a DMARD-free follow-up period for at least 1 year, to ensure that DMARD-free remission is sustainable.”
Verstappen M, van Mulligen E, de Jong PHP, van der Helm-Van Mil AHM. DMARD-free remission as novel treatment target in rheumatoid arthritis: a systematic literature review of achievability and sustainability. RMD Open. 2020;6(1):e001220.