Araujo EG, Finzel S, Englbrecht M, et al., High incidence of disease recurrence after discontinuation of disease-modifying antirheumatic drug treatment in patients with psoriatic arthritis in remission. Ann Rheum Dis 2015;74:655-660 doi:10.1136/annrheumdis-2013-204229.
Because of the high costs and risks of some inflammatory arthritis treatments, rheumatologists and patients alike wonder whether it is possible to reduce or even curtail medication when disease activity is low or minimal.
In rheumatoid arthritis (RA), studies suggest that sustained remission for some patients is indeed possible. But in psoriatic arthritis (PsA), this small prospective study from Germany finds an “extraordinary high rate of recurrence” even among patients who reach and maintain drug-free remission.
Looking at 26 PsA patients (20 men and 6 women, all their mid ‘50s) judged to be in continuous remission on methotrexate monotherapy or a tumor necrosis factor alpha (TNFα) blocker, these researchers find that once the drug is discontinued the disease comes back and joint destruction resumes.
“More than two-thirds of the patients had to restart their original medication within the first 6 months of cessation of treatment,” they note. “One additional patient developed disease activity only 30 days after the 6-month follow-up visit, suggesting that recurrence of PsA can occur even after a 6 months of symptom-free interval.”
In this study, patients most likely to relapse are men with longer disease duration and more skin involvement.
One reason for relapse may be that anti-rheumatic drugs do not alter the underlying susceptibility to PsA, and that affected areas may harbor inflammatory tissue even when the joints are not painful or swollen.
Inflammation-related injury may “prime” these joints for disease and set the stage for recurrence.
This study raises a more fundamental question about PsA: Whether a genetic susceptibility-altered immune response “may persist lifelong in patients with PsA and cannot be corrected by current antirheumatic interventions,” as the researchers put it.
In contrast, studies of RA remission show reversal of joint damage with biological drug treatment.
In RA, long-term drug-free remission has been shown achievable; some patients may be able to enjoy low disease activity at reduced medication doses.
Although more research is needed, this small study implies the same may not be possible in PsA.
Previous studies have shown that TNFα inhibitors do minimize disease activity in PsA. The findings in the study above “would further strengthen the importance of early intervention in PsA, which may ... enhance the likelihood of remission of disease damage of the entheseal organ,” these researchers conclude.
Although DMARD therapy reinstated remission once therapy was re-started, they add, discontinuing therapy “cannot be recommended for PsA patients.”