THU0189 A PROSPECTIVE STUDY OF TAPERING CONVENTIONAL DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (C- DMARDS) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA) IN STABLE REMISSION
Authors: SHAH ROMI, Canchi Balakrishnan
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Remission in RA is being achieved more often nowadays with effective early aggressive therapy with DMARDS. Studies ((1 2 3 4)) have shown that it is possible to taper and stop biologic DMARDS in patients with RA in stable remission. However there are no such studies or recommended protocols for c-DMARDS treated patients. <h3>Objectives</h3> To study the incidence and timing of flares in RA patients in sustained remission of at least 6 months duration on slow withdrawal of c-DMARDS and to identify predictors of flares. <h3>Methods</h3> Consenting adult(age &gt;18 years) RA patients satisfying the ACR 2010 criteria attending our outpatient department with a disease duration of minimum 1 year and a stable remission (CDAI &lt;2.8 on consecutive 2 visits at 3 months interval in last 6 months) on c- DMARDS were included. Patients receiving steroids or biologics were excluded. Protocol for tapering: On monotherapy: 50% dose reduction 3 weekly and stop eventually On combination therapy: sequential dose reduction as monotherapy followed by stoppage of cDMARDs(in order from first to last: hydroxychloroquine, sulphasalazine, leflunomide, methotrexate) Flare was defined as CDAI of &gt;2.8. Number of RA flares and timing of flares were noted. Predictors of flare were analysed using univariate and multivariate regression <h3>Results</h3> 66 patients satisfied inclusion criteria of which 5 did not consent, 5 committed protocol violation and 2 lost to follow up. Total 54 patients were included in the final analysis. 42 patients (77.78%) flared during the study period. Of these 42 patients, 29(69.05%) flared whilst on the tapering protocol whereas, 13 (30.95%) flared after complete withdrawal of c-DMARDs. 20 patients (47.62%) flared within first 3 months of the tapering regimen and total 31 patients (73.8%) flared within first 6 months of tapering regimen. Baseline CDAI scores were significantly higher in patients who developed flare compared to those who remained in remission (0.82±0.82 v/s 0.29 ±0.54, p=0.04). RF positivity and age more than 60 years were predictors of flare in univariate regression analysis. With multivariate logistic regression, RF positivity was the only variable significantly associated with risk of flare (p=0.0098, SE =1.62 OR 66.31). <h3>Conclusion</h3> We found that on tapering of c DMARDs at 3 weekly interval in RA patients with stable remission the incidence of flare was 78%. Most flared during tapering therapy itself and not after the drugs were stopped. Rheumatoid factor positivity seemed to predict flares. Although within the definition of remission, CDAI scores at baseline were significantly higher in patients who developed flare compared to those who remained in remission.CDAI has limitation in defining remission and inclusion of imaging in defining remission may lead to better remission on tapering cDMARDs. <h3>References</h3> [1] Schett G, Emery P, Tanaka Y, Burmester G, Pisetsky DS, et al. Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis. 2016Aug;75(8):1428–37. [2] Haschka J, Englbrecht M, Hueber AJ, Manger B, Kleyer A, et al. Relapse rates in patients with rheumatoid arthritis in stable remission tapering or stopping antirheumatic therapy: interim results from the prospective randomised controlled RETRO study. Ann Rheum Dis. 2016Jan1;75(1):45–51. [3] Fautrel B, Pham T, Alfaiate T, Gandjbakhch F, Foltz V, et al. Step-down strategy of spacing TNF-blocker injections for established rheumatoid arthritis in remission: results of the multicentre non-inferiority randomised open-label controlled trial (STRASS). Ann Rheum Dis. 2016Jan;75(1):59–67. [4] Huizinga TWJ, Conaghan PG, Martin-Mola E, Schett G, Amital H, et al. Clinical and radiographic outcomes at 2 years and the effect of tocilizumab discontinuation following sustained remission in the second and third year of the ACT-RAY study. Ann Rheum Dis. 2015Jan28;74(1):35–43. <h3>Disclosure of Interests</h3> None declared