Psoriatic arthritis

‘Window of opportunity’: TNFi induce high rates of remission in early SpA


Early use of anti‐TNF treatment in peripheral spondyloarthritis (pSpA) can achieve sustained drug-free clinical remission in more than 50% of patients, a European study has shown.

In a trial that backs the “window of opportunity” hypothesis for treatment of the very early stages of pSpA, patients whose treatment with golimumab was started within 12 weeks of symptom onset were able to maintain remission for 18 months after withdrawal of the drug.

Published in Arthritis and Rheumatology, the trial involved 60 DMARD-naïve patients with pSpA of less than 12 weeks duration who were treated with either golimumab (n=40) or placebo (n=20).

Most of the patients in the trial achieved clinical remission (defined as absence of arthritis, enthesitis and dactylitis) at 24 weeks after starting treatment, after which treatment was withdrawn.

All patients had at least 18 months follow up, at which time 53% of patients (49 of the 60) were still drug free remission.

Of the 49 patients achieving sustained clinical remission, only four were from the placebo arm, whereas all other patients were treated with golimumab from baseline or used the rescue arm with golimumab treatment.

Ten patients who did not reach ‘sustained clinical remission’ were major responders defined as meeting the Peripheral Spondyloarthritis 40% Response Criteria .

The study authors, from the  Department of Rheumatology Ghent University Hospital, Belgium, said the findings showed that drug free remission was an achievable target in early pSpA for a high proportion of patients.

“According to the so called ‘window of opportunity’ hypothesis, the immune mediated inflammatory process underlying pSpA becomes less reversible over time, which could be reflected in changes in therapeutic efficacy. The data presented here underscore the potential of such a strategy in at least half of the pSpA patients,” they wrote.

“One could anticipate that chronic stages of the disease are marked by increased loss of tolerance, epigenetic modifications, or impaired immunoregulatory pathways. Such mechanisms could account for the distinct drug free remission rates in the present study as opposed to other studies with more established forms of pSpA ,” they added.

While the results will need to be confirmed in large multicentre studies, the proof-of-concept study highlighted the potential good outcomes from early recognition and referral from primary care to rheumatologists, in order to permit early remission induction, they concluded.

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