The importance of achieving early remission to stop progression of RA took centre stage at this 2015 EULAR satellite symposium on Wednesday.
Over the past 5 years, treat to target (T2T) has changed our approach in clinical rheumatology. T2T was demonstrated to be effective in clinical research trials and today, research is showing that T2T also works in real-life RA cohorts. Recent studies have shown that when patients achieve remission, work capacity essentially returns to normal. However, comorbidity increases disability regardless of disease activity, even for those in clinical remission.
Could we do even better by targeting early remission? We know that synovitis is directly correlated to erosions, and that subclinical synovitis predicts radiographic progression in patients as measured by power Doppler. Dr. Paul Emery discussed how sensitive imaging techniques such as MRI can show evidence of erosions before changes become apparent on with other imaging modalities such as x-rays. He concluded that imaging is an essential adjunct to clinical assessment, and sensitive imaging may detect disease activity in joints even when the joints are asymptomatic.
Once patients are in remission, what’s next? Could T2T help clinicians maximize treatment outcomes without over-treating RA patients? The EULAR guidelines recommend removing steroids and possibly discontinuing biologics. But we don't know who will respond well to discontinuing biologics or the best approach to stopping treatment. Dr. Arthur Kavanaugh discussed several studies that are shedding some light on this important issue.
In the OPTIMA trial, clinical response was maintained in patients with early RA after the TNFi was withdrawn from a regimen of TNFi + MTX
In the PRIZE study, patients did better when they received a low dose of medication for an additional year instead of discontinuing treatment completely. A greater speed and depth of response to TNFi + MTX predicted the ability to taper TNFi in early RA.
The PRESERVE study looked at the effect of dose reduction and suggests that most patients do better on a half or a full dose of the TNFi.
Increasing the dosing interval of TNFi therapy in the DRESS study resulted in a higher cumulative incidence of major flares compared to usual care at 18 months. Some patients could lengthen therapy and some were able to come off therapy altogether. But those who flared received more steroids and DMARDs, and they also had more radiographic changes.
Dr. Kavanaugh concluded that for patients who achieve long-term remission, dose optimization must be considered. However, we need more research to determine who will respond well to removing therapy and whether dose reduction or increasing the dosing interval is the best approach.