Rheumatoid arthritis

Holy grail of sustained remission ‘elusive’ for some RA patients: experts

Biologic therapy is more effective than triple therapy with conventional DMARDs for achieving sustained remission (SR) after an inadequate response to methotrexate monotherapy in patients with rheumatoid arthritis.

Patients were also more likely to stay on biologic therapy than triple therapy, according to data from 1,502 patients in the Swedish Rheumatology Quality Register.

However the researchers said their findings also showed that a subgroup of patients respond well to triple therapy.

The study, published in Arthritis & Rheumatology, compared patients on biologics plus methotrexate with those on methotrexate plus sulfasalazine and hydroxychloroquine or chloroquine.

It found more patients receiving biological therapy remained on therapy compared to patients receiving triple therapy – 64% v 52% at 1 year; 43% v 35% at 2 years.

For patients starting therapy, the odds ratios for achieving sustained remission were 1.79 with biologic therapy v 1.86 with triple therapy at 1 year and 1.92 v 1.62 respectively at 2 years.

“However, we found similar effectiveness for achieving short-term and long-term SR among patients remaining on biological vs. triple therapy at 1 and 2 years from treatment start, and at any time during follow-up among patients started on either of the strategies and irrespective of therapy retention,” the study said.

The odds ratio dropped in patients remaining on therapy to 1.12 and 1.31 respectively at 1 year and 0.85 and 0.76 respectively at 2 years.

They said although the likelihood of reaching sustained remission was higher with biologics, triple therapy may still be an alternative for certain patients.

“These are meaningful findings for patients with contraindications to biological therapy and of economic interest with regards to cost differences between the strategies and hence resource allocations.”

An editorial in the journal, co-authored by Queensland rheumatologist Associate Professor Peter Nash, said the study was important as the use of triple therapy has become less prominent in rheumatoid arthritis recommendations and guidelines.

“Treatment after methotrexate with a bDMARD compared to adding csDMARDs as triple therapy is more likely to result in sustained DAS28(ESR) remission and be continued because of the better clinical benefit and tolerability.”

“However, patients who do respond and tolerate triple therapy, are just as likely to achieve and maintain sustained DAS28(ESR) remission; just a smaller percent of initial patients do so.”

They noted that the holy grail of sustained remission for all was elusive – with neither treatment strategy effective for all patients.

“This analysis suggests that despite advances in treatment strategies and therapeutic options, the likelihood of sustained remission over 2 years with either strategy in their rheumatology practices remains low with more than half the patients discontinuing treatment by 2 years. These results do not bode well for a lifelong chronic disease.”

They added that without predictors of tolerability and response to medications, “our current treatment paradigm of blindly choosing a specific treatment option after methotrexate failure in RA is sub-optimal.”

“Perhaps biomarkers will provide more rationale treatment choices and inform us when to start or stop a medication but the search for such biomarkers has been disappointing.”

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