Rheumatoid arthritis relapses?

*It is only for medical professionals to read for reference.
The medicine is not that you can reduce the stop if you want to reduce the stop, you have to rely on the facts to speak! The need for long-term medication has always been a pain point for patients with rheumatoid arthritis (RA).
The goal of RA treatment is to clinically relieve and prevent structural joint damage
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After RA patients are treated with traditional synthetic disease-improving anti-rheumatic drugs (csDMARDs), clinical remission has become an achievable goal, but how to treat it during the clinical remission period is still unclear
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Note: How to judge "clinical remission", currently the following definitions are commonly used: disease activity (DAS28)-ESR or CRP ≤ 2.
6; clinical disease activity index (CDAI) ≤ 2.
8; simplified disease activity index (SDAI) ≤ 3.
3; Boolean mitigation standards
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Here comes a classic question: Is it all right after clinical remission? Can the medicine be reduced or even not taken? It is really too young, too simple drugs have been halved, and the recurrence rate has gone up.
A study published by JAMA evaluated the effect of csDMARDs reduction treatment on the onset of RA in patients with RA remission compared with conventional dose csDMARDs treatment
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ARCTIC REWIND is a multi-center, randomized, parallel, open non-inferiority study conducted in rheumatology practice centers in 10 hospitals in Norway
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From June 2013 to June 2018, a total of 160 RA patients were enrolled.
All patients achieved clinical remission for more than one year and are now receiving stable csDMARDs treatment.
The last visit was in June 2019
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Patients were randomly assigned to the half-dose csDMARDs group (n=80) and the regular-dose csDMARDs group (n=80)
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The primary endpoint was the proportion of patients who had disease recurrence during the baseline examination and 12-month follow-up
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Disease activity is defined as a disease activity score (DAS) greater than 1.
6 (RA remission threshold), a DAS score increase of 0.
6, or at least 2 joint swelling
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If both the patient and the investigator agree that a clinical recurrence has occurred, it can also be recorded as a disease recurrence
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Of the 160 registered patients (66% were women, with an average age of 55.
1± years), 155 patients were included in the main analysis population (77 patients received half-dose csDMARDs, 78 patients received regular doses of csDMARDs)
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In the main analysis population, 19 of 77 patients (25%) who received half-dose csDMARD treatment had at least one relapse during the 1-year follow-up period, while 5 of 78 patients in the conventional-dose csDMARD treatment group (6 %) recurrence (risk difference 18%, 95% CI 7%-29%); compared with the conventional dose group, the recurrence rate of the half-dose group is statistically significantly higher (in the vernacular, the drug is reduced , The recurrence went up)
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Nineteen patients (25%) in the half-dose csDMARD group developed dizziness, while 5 patients (6%) in the regular-dose csDMARD group developed dizziness (risk difference 18%, 95% CI 7%-29%)
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Adverse events occurred in 34 patients (44%) in the half-dose group and 42 patients (54%) in the regular-dose group, but there were no adverse events that led to the discontinuation of the study
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There were no deaths in the two groups
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Figure 1: Cumulative recurrence rate within 12 months of the two treatment groups Figure 2: Recurrence rate of half-dose and conventional dose groups for 12 months Table 1: Adverse events from month 0 to month 12 This study is very clear It is pointed out that after RA patients reach clinical remission, they should continue to be given regular doses of csDMARDs, and the dose should not be reduced or stopped arbitrarily! Otherwise, the weight reduction will be cool for a while, and the relapse will be "cool" from time to time! What if you really want to reduce weight? Is it possible? Be cautious when reducing the dose.
The 2015 version of the Rheumatoid Arthritis Treatment Guidelines recommends that RA patients who have achieved clinical remission can reduce DMARDs (including csDMARDs, tsDMARDs and bDMARDs), while the 2021 version of the guidelines states that for those who have achieved remission or have low disease activity (LDA) For patients, when to reduce the drug and how to achieve the best drug reduction is still lack of research data for reference.
Therefore, the expert group recommends that when patients are willing to reduce the dose of DMARD, they can consider reducing the drug carefully
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During the drug reduction period, the patient should be carefully evaluated, and if there is a recurrence, the previous plan should be resumed immediately
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Table 2: Recommendations related to the 2021 version of ACR drug reduction.
In short, for the reduction and discontinuation of DMARDs, the guidelines recommend: continue to use the current dose> reduction> gradual discontinuation> sudden discontinuation
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References: [1]JAMA.
2021 May 4;325(17):1755-1764.
[2]Effect of Half-Dose vs Stable-Dose Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Disease Flares in Patients With Rheumatoid Arthritis in Remission :The ARCTIC REWIND Randomized Clinical Trialhttps://pubmed.
ncbi.
nlm.
nih.
gov/33944875/