Background Tapering of medication in rheumatoid arthritis (RA) patients is becoming increasingly important due to the effectiveness of both biological therapy and tight-controlled treatment. Patients are able to reach the state of remission in which they may be able to taper their medication. Whom to taper and when to taper (amount of time in remission) is unclear. Ultrasound (US) data from cross-sectional studies suggest that the presence of subclinical synovitis might increase the risk of disease flare preventing patients to be tapered.
Objectives To describe the frequency of flare and to relate this to the presence of subclinical synovitis measured by US in RA patients that continue synthetic and biological DMARDs for 3 months while being in remission.
Methods Patients who are participating in the TARA study and were examined by US were selected for this analysis. TARA is a single blinded randomized controlled trial that includes RA patients (aged >17 years) who are treated with the combination of a synthetic DMARD and adalimumab or etanercept and are in remission (DAS44 <2.4 & SJC ≤1). In the first 3 months of this study patients continue their medication and if they maintain their disease state, are randomized to (i) tapering the synthetic DMARD or (ii) tapering their TNF blocker. US examination included 26 joints (MCP2-5, PIP2-5, wrists, MTP2-5) graded on greyscale (GS; 0-3) and power Doppler (PD; 0-3). A joint with subclinical synovitis was defined as GS>1 and/or PD>0, while flare was captured by DAS44 ≥2.4 or SJC>1.
Results Three out of 67 patient (4%) experienced a flare while continuing their combination of synthetic and biological treatment. These 3 patients showed subclinical synovitis in at least one joint at the US examination. Another 36 patients were also positive on US, but did not experience a flare. The 28 patients that were US negative did not differ from the US positive cases if we compared clinical features such as tender joints, rheumatoid factor or acute phase reactants. ACPA was slightly higher in the US negative group but did not reach statistical significance.
Conclusions A low flare rate (4%) was observed among patients in remission continuing their combination therapy of synthetic and biological DMARDs for 3 months, while 2/3 of the patients had a least one positive ultrasound joint at baseline. Although the patients who flared were all US positive, using GS>1 and/or PD>0 in at least one joint might not be sufficient to discriminate who will clinically flare.
Disclosure of Interest None declared