James Edwards
Authors: M. C. R. Childs
Journal: BMJ (2014)

<h3>Background</h3> Disease-modifying anti-rheumatic drug (DMARD)-free remission is an achievable outcome in rheumatoid arthritis (RA). The influence of treatment strategy on the ability to achieve and sustain this outcome is unclear. Therefore, we compared the prevalence and sustenance of DMARD-free remission in RA-patients treated in a trial with intensive DAS-steered care aimed at DMARD-free remission versus RA-patients treated to target in routine care. <h3>Methods</h3> 279 consecutive RA-patients (2010-criteria), diagnosed in the Leiden University Medical Centre between March 2007-September 2010, were studied. Of these, 155 participated in a DAS &lt;1.6 steered trial aimed at DMARD-free remission (IMPROVED-study). These patients were initially treated with high-dose prednisone (60 mg/day) and methotrexate. Medication was intensified in case of a DAS ≥1.6 and tapered in case of a DAS &lt;1.6. The other 124 RA-patients were treated according to routine care, consisting of initial methotrexate and subsequent DAS &lt;2.4 steered treatment. The median follow-up was 7.8 years. Medical records were studied on achieving DMARD-free remission, defined as the absence of synovitis for ≥1 year after DMARD-cessation, and ‘late flares’, defined as recurrence of clinical synovitis ≥1 year after DMARD-cessation. Sustained DMARD-free remission was defined as the sustained absence of clinical synovitis after DMARD-cessation for ≥1 year <i>and</i> the total follow-up duration; i.e. patients with a late flare were not in this group. Percentages of remission and late flares were compared between the two treatment strategies, in all patients and after stratification by ACPA. <h3>Results</h3> Patients receiving intensive treatment were more often ACPA-positive (59% vs 40%). DMARD-free remission was achieved by 35% of patients receiving intensive treatment and by 29% of patients receiving routine care (HR 1.2, 95% CI: 0.8 to 1.8). Within the ACPA-positive and ACPA-negative strata patient characteristics were similar, except for a younger age in patients receiving intensive treatment. Within ACPA-positive patients, DMARD-free remission was achieved more often in the intensive treatment group than in the routine care group (25% vs 6%, HR 4.9, 95%: CI: 1.4 to 17, corrected for age). In ACPA-negative patients no differences were observed (49% vs 44%, HR 1.1, 95% CI: 0.6 to 1.8, corrected for age). A late flare occurred in 20% of patients receiving intensive treatment and in 8% of patients receiving routine care (HR 2.3, 95% CI: 0.6 to 8.3). After excluding late flares from the remission group, the prevalence of DMARD-free <i>sustained</i> remission was not different for both treatment strategies in the total group (28% vs 27%, HR 1.0, 95% CI: 0.6 to 1.5). Also in the ACPA-positive group no significant effect remained (17% vs 6%, HR 3.1, 95% CI: 0.9 to 11, corrected for age). <h3>Conclusions</h3> An intensive treatment strategy was not associated with a higher prevalence of DMARD-free sustained remission compared to up-to-date routine treatment. Within ACPA-positive RA, intensive treatment resulted in more remission but also in more late flares. Together these data do not provide evidence to prioritise the studied intensive treatment strategy above current routine care. <h3>Disclosure of Interest</h3> None declared