Background The severity of joint destruction has decreased during the last decennia and the result of changes in treatment strategies. Because joint destruction is a less relevant disease outcome nowadays, other long-term outcomes will become more important, as DMARD-free sustained remission that reflects loss of arthritis persistence.
Objectives To determine if DMARD-free sustained remission, the sustained absence of synovitis after cessation of DMARD-therapy, is a relevant long-term outcome of rheumatoid arthritis (RA) we investigated if (1) its occurrence is promoted by treatment and (2) its status reflects subsidence of symptoms and resolution of disability.
Methods We studied 1007 patients who were diagnosed with RA 1993-2011 and included in the Leiden Early Arthritis Clinic. Patients included in 1993-1995 were initially treated with NSAIDs, in 1996-1998 mild DMARDs were started early, from 1999 onwards methotrexate was initiated promptly and from 2005 onwards DAS-steered treatment was common. These periods were used as proxy for differences in treatment strategy. Rates of DMARD-free sustained remission rates were compared using Kaplan-Meier curves and Cox proportional regression.
Results In total, 155 patients achieved DMARD-free sustained remission. Baseline patients' characteristics, including prevalence of ACPA, were not different across inclusion periods. The treatment strategies associated significantly with achieving remission (p<0.001). Patients that were treated according to more recent treatment strategies achieved remission more often (p<0.001). The mean time to remission (SD) was 7.8 (3.4), 6.9 (4.0), 4.8 (2.7) and 3.1 (1.4) years for patients treated with the subsequent treatment strategies. The difference between the treatments groups remained statistically significant when Kaplan-Meier analyses were repeated limiting the latest inclusion period till January 2009, and limiting the maximal follow-up to 5 years in all groups (both analyses p<0.001).
Cox regression adjusted for ACPA/RF, SJC, ESR, CRP revealed HRs for DMARD-free sustained remission of 1.13 (95% CI 0.48-2.64) in patients early treated with mild DMARDs, 2.39 (95%CI 1.07-5.32) in patients treated with early methotrexate, and 3.72 (95%CI 1.60-8.62) in those early treated with methotrexate and DAS-steered therapy.
At the time of remission, the HAQ was at the level of the general population (median 0.13, IQR 0-0.63). Also patients'-rated VAS morning stiffness, fatigue, pain and disease activity were low (median (IQR) mm, 14 (2-27), 10 (0-47), 6 (0-20), 7 (0-20) respectively).
Conclusions More intensive treatment strategies increased the chance for DMARD-free sustained remission, indicating this long-term outcome is to pursue and that RA chronicity can be influenced. RA-patients with DMARD-free sustained remission have a normalized functional status.
Disclosure of Interest None declared