Background The advancement in biological agents (Bio) and improvement in treatment strategy enabled patients with rheumatoid arthritis to achieve remission or to achieve low disease activity. On the other hand, the cost of Bio has become a major problem in health economics and for some patients Bio therapy is not affordable. In this situation, it is important for us to consider whether we should discontinue or extend the interval of Bio.
Objectives To investigate Bio-holiday therapy for rheumatoid arthritis patients with clinical disease activity index (CDAI) remission.
Methods Thirty seven rheumatoid arthritis (RA) patients with CDAI remission were included in this study. The patients were classified into two groups. Bio-holiday group (group H) consisted of 17 patients (etanercept (ETA) 5, golimumab (GLM) 8, tocilizumab (TCZ) 4 patients) where the patients were off from Bio if they achieved CDAI remission. Methotrexate was combined for all patient. They had to visit our clinic at least once in every two months, and were treated with Bio within 3 months after falling out of CDAI remission. They could be off from Bio again once they've reached CDAI remission. Bio group (group C) consisted of 22 patients (ETN 7, GLM 9, TCZ 6 patients). The mean ages of the two groups were 55.6 for H and 58.3 years old for C group and the mean disease duration were 4.45 and 4.96 years. There were no statistical differences between the backgrounds of both groups. CDAI, the van der Heijde-modified total sharp scores  (mTSS) and health assessment questionnaire  (HAQ) were compared between both groups.
Results The mean withdrawal periods were 11.8 (GLM), 6.5 (ETN) and 10.0 months (TCZ) respectively. Two patients in group H and 3 patients in group C dropped out due to financial reasons. One patient in each group dropped out due to flare-up. None of the patients discontinue their therapy for adverse events in both groups. Except for one patient who dropped out from CDAI remission due to flare-up in H group, all the other patient were able to achieve CDAI remission without delay. There were no statistical differences in CDAI throughout the period of study (Figure). There were no statistical differences in ΔmTSS (group H -0.18/year and group C -0.24/year) and HAQDI (group H; 0.12, 0.08 and group C; 0.10, 0.08 at baseline and at final evaluation respectively).
Conclusions We conclude that it is possible to keep disease activity, radiographic progression and physical function by Bio-holiday for RA patients with CDAI remission under tight control strategy. As the flare-up rate of RA patients with deep remission is not so severe, it is not difficult for us to restart Bio therapy and gain CDAI remission. In addition it is financially durable and thus we recommend bio-holiday therapy.
van der Heijde D, et al. J Rheumatol. 2000;27:261–3
Siegert CE, et al. Clin Rheumatol. 1984;3:305–9
Disclosure of Interest None declared