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Could the Natural History of pSpA Change with Very Early Treatment?
June 15 2017 10:01 AM ET — via RheumReports
The natural evolution of peripheral SpA (pSpA), especially in the early phases, is poorly understood. At present, it is unclear whether early aggressive treatment is required in these patients like it is in early rheumatoid arthritis or axial SpA.
The randomized control trial, Clinical REmission in peripheral SPondyloArthritis (CRESPA), is trying to address this question, and the results were presented in the abstracts session (OP0026) at EULAR on June 14. The objective of the study was to evaluate the efficacy of golimumab for the induction of clinical remission in patients with very early, active pSpA.
The study enrolled patients who fulfilled the ASAS classification criteria for pSpA and had a symptom duration of ≤12 weeks. Patients were randomized to receive golimumab 50 mg every 4 weeks or placebo. The primary outcome was the achievement of clinical remission at week 24, defined as the absence of arthritis, enthesitis and dactylitis. After week 24, the study entered an open-label phase that continued to week 48.
In patients who achieved sustained remission (defined as two consecutive visits in clinical remission) the study drug was withdrawn. It should be noted that 40% of the study patients had psoriasis and fulfilled the CASPAR criteria for PsA.
The results showed that a significantly higher proportion of patients on golimumab achieved remission at week 24 compared to placebo (75% vs. 20%, p<0.001). Sustained clinical remission was achieved in >80% of patients, most of them by week 24. Among patients for whom medication was withdrawn, 53% achieved drug-free remission and 47% relapsed (mean follow up 18 months). High joint count (>5 active joints) and preexisting psoriasis were predictors of poor response and psoriasis also predicted relapse.
These results suggest that TNF inhibition in patients with very early peripheral SpA is associated with very high chances of achieving clinical remission. The results of the placebo arm suggest that the chance of spontaneous remission in these patients is low. A significant proportion of patients could also remain in a state of drug-free remission after treatment withdrawal.
The main limitation of the study is that it included a mixed population of pSpA with a significant proportion of patients who met the criteria for PsA and other patients with non-differentiated pSpA. The natural course of these two conditions may be different.
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About the Author
Dr. Lihi Eder
Dr. Lihi Eder is an Assistant Professor of Medicine at the University of Toronto and Staff Rheumatologist and Director of the Psoriatic Arthritis Research Program at Women’s College Hospital. Dr. Eder is a Scientist at Women’s College Research Institute and associate member of the graduate faculty at the Institute of Medical Science.
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