Background The introduction of DAS-driven intensive treatment strategies in early rheumatoid arthritis (RA) has allowed the achievement of drug-induced clinical remission in a significant percentage of cases. Previous studies have also suggested the possibility, in selected patients, of remission maintenance for prolonged periods following treatment suspension. Despite these observations, three critical issues remain unsolved: 1) whether achievement of stable clinical remission and suppression of inflammation can coincide with reversal of the pathogenetic process, 2) the possibility to define parameters able to predict in which patients treatment can be suspended, 3) the primary dynamics as well as the anatomic and biologic substrate of relapse.
Objectives To investigate, through a pilot assessment, the clinical outcome and ultrasonographic-synovitis dynamics of RA patients in DMARDs-induced SDAI remission, during a 12 months drug-free follow-up.
Methods From December 2011, all RA patients followed at the Pavia's Early Arthritis Clinic achieving stable clinical remission and candidate to treatment suspension are referred to a dedicated Remission Clinic (RemC). Inclusion criteria for RemC referral: 1) introduction of DMARDs treatment within 12 months from symptoms' onset, 2) at least 24 months DMARDs treatment with a DAS28-driven intensive protocol, 3) stable DAS28 clinical remission (DAS28<2.6) for at least 6 months in the absence of corticosteroids. All patients allowed to drug-free follow-up at RemC are monitored at three months' intervals (for the first 12 months) through complete clinical, ultrasonographic (hands-feet-axillary lymph nodes) and immunologic screenings. Hands-feet radiographs are performed at baseline and every 12 months. Treatment with DMARDs is re-introduced in case of moderate disease activity (MDA, DAS28>3.2) or radiographic progression.
Results 32 consecutive RA patients (females n=22, ACPA positive n=10) in DAS28 and SDAI remission (SDAI<3.3) at the baseline visit have been followed-up for 12 months after treatment withdrawal and monitored every 3 months. Treatment re-introduction due to MDA was required in 9/32 patients (28%) during follow-up. In 7/32 (22%) it was observed unstable remission with transient states of low disease activity, while in 16/32 patients (50%) stable DAS28 remission was maintained in all visits (T0-T12). Ultrasonographic stratification at baseline showed the absence of power Doppler signal in hands-wrists in 23/32 of patients (SDAI<3.3-PD=0). Despite the absence of clinical and sub-clinical signs of synovitis at recruitment, 5/23 (22%) patients relapsed, while in 11/18 (61%) a transient or persistent reappearance of defined PD signal (PD>1) was detected during follow-up despite the lack of requirement of DMARDs re-introduction according to study criteria.
Conclusions Suspension of DMARDs with short term maintenance of good clinical status is an achievable goal after treat-to-target and tight control strategies in early RA. However, despite the presence of stringent clinical and ultrasonographic remission, signs of disease reactivation can be observed in some patients during follow-up, suggesting the requirement of additional insights into the prognostic and pathologic stratification of RA remission phase.
Disclosure of Interest : None declared