Verstappen M, van Mulligen E, de Jong PHP, van der Helm-Van Mil AHM. DMARD-free remission as novel treatment target in rheumatoid arthritis: A systematic literature review of achievability and sustainability.
RMD Open 2021;
6:rmdopen-2020-001220. [PMID:
32393523 PMCID:
PMC7299506 DOI:
10.1136/rmdopen-2020-001220]
[Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 01/08/2023] Open
Abstract
Objectives
Although current treatment guidelines for rheumatoid arthritis (RA) suggest tapering disease-modifying anti-rheumatic drugs (DMARDs), it is unclear whether DMARD-free remission (DFR) is an achievable and sustainable outcome. Therefore, we systematically reviewed the literature to determine the prevalence and sustainability of DFR and evaluated potential predictors for DFR.
Methods
A systematic literature search was performed in March 2019 in multiple databases. All clinical trials and observational studies reporting on discontinuation of DMARDs in RA patients in remission were included. Our quality assessment included a general assessment and assessment of the description of DFR. Prevalence of DFR and its sustainability and flares during tapering and after DMARD stop were summarised. Also, potential predictors for achieving DFR were reviewed.
Results
From 631 articles, 51 were included, comprising 14 clinical trials and 5 observational studies. DFR definition differed, especially for the duration of DMARD-free state. Considering only high- and moderate-quality studies, DFR was achieved in 5.0%–24.3% and sustained DFR (duration>12 months) in 11.6%–19.4% (both relative to the number of patients eligible for tapering). Flares occurred frequently during DMARD tapering (41.8%–75.0%) and in the first year after achieving DFR (10.4%–11.8%), while late flares, >1 year after DMARD-stop, were infrequent (0.3%–3.5%). Many patient characteristics lacked association with DFR. Absence of autoantibodies and shared epitope alleles increased the chance of achieving DFR.
Conclusions
DFR is achievable in RA and is sustainable in ~10%–20% of patients. DFR can become an important outcome measure for clinical trials and requires consistency in the definition. Considering the high rate of flares in the first year after DMARD stop, a DMARD-free follow-up of >12 months is advisable to evaluate sustainability.
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