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Discontinuing treatment in patients with rheumatoid arthritis in sustained clinical remission: exploratory analyses from the BeSt study
  1. N B Klarenbeek1,
  2. S M van der Kooij1,
  3. M Güler-Yüksel1,
  4. J H L M van Groenendael2,
  5. K H Han3,
  6. P J S M Kerstens4,
  7. T W J Huizinga1,
  8. B A C Dijkmans4,5,
  9. C F Allaart1
  1. 1Leiden University Medical Center, Leiden, The Netherlands
  2. 2Sint Franciscus Hospital, Roosendaal, The Netherlands
  3. 3Maasstad Hospital, Rotterdam, The Netherlands
  4. 4Jan van Breemen Institute, Amsterdam, The Netherlands
  5. 5VU Medical Center, Amsterdam, The Netherlands
  1. Correspondence to N B Klarenbeek, Leiden University Medical Center, P O Box 9600, 2300 RC Leiden, The Netherlands; n.b.klarenbeek{at}lumc.nl

Abstract

Objectives To determine the relapse rate after discontinuing treatment in patients with rheumatoid arthritis (RA) in sustained clinical remission, to identify predictors of a relapse and to evaluate treatment response after restarting treatment.

Methods Five-year data from the BeSt study were used, in which 508 patients with recent-onset RA were randomised into four dynamic treatment strategies, aiming at a disease activity score (DAS) ≤2.4. When DAS was <1.6 for ≥6 months, the last disease-modifying antirheumatic drug (DMARD) was tapered and discontinued. If DAS increased to ≥1.6, the last DMARD was immediately reintroduced.

Results During a 5-year period, 115/508 patients (23%) achieved drug-free remission. Of these, 53 patients (46%) restarted treatment because the DAS was ≥1.6 after a median of 5 months, 59 patients (51%) remained in drug-free remission for a median duration of 23 months and 3 (3%) were lost to follow-up. In those who restarted treatment, mean (SD) DAS increased from 1.13 (0.73) at remission before tapering to 2.18 (0.65) at restart, reflecting an increase in all four components of DAS. Multivariable predictors for restarting treatment were anti-cyclic citrullinated peptide (anti-CCP), last DMARD sulfasalazine, low baseline Health Assessment Questionnaire score and high mean DAS until remission. Of the 53 patients who restarted treatment, 39 (74%) again achieved remission 3–6 months after the restart. The median (IQR) damage progression in those who restarted treatment during the year of DAS increase was 0 (0–1) Sharp-van der Heijde units.

Conclusion During 5 years DAS steered treatment, nearly 25% of patients with RA achieved drug-free remission; 46% restarted DMARD monotherapy because of a relapse, the majority of whom again achieved clinical remission within 3–6 months without showing radiological progression during the relapse.

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Footnotes

  • Funding This study was funded by a grant from the Dutch College of Health Insurances (College Voor Zorgverzekeringen) with additional funding provided by Scheringh-Plough BV and Centocor. The authors, not the sponsors, were responsible for the study design, collection, analyses and interpretation of all data, the writing of the article and the decision to publish.

  • Competing interests TWJH, BACD and CFA received speakers' fees from various pharmaceutical companies (less than US$5000 per year).

  • Ethics approval This study was conducted with the approval of the medical ethical committees of the participating hospitals. All patients gave written informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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