Can disease flare be predicted following remission and treatment withdrawal in patients with early rheumatoid arthritis?

This study identified predictors of disease flare in patients with early, active rheumatoid arthritis (RA) that had stopped methotrexate (MTX; Otrexup) and/or abatacept (Orencia) treatment after clinical remission was achieved at 12 months. The data showed that patient function (HAQ-DI) and bone erosion based on magnetic resonance imaging (MRI) scans predicted disease flare at 6 months and 12 months after treatment withdrawal.

RA is a chronic, inflammatory joint disease that causes joint damage, swollen joints, and disability. Symptoms of RA include pain, fatigue, and reduced quality of life (QoL). Disease-modifying anti-rheumatic drugs (DMARDs) are used during early RA treatment until reduction or disappearance of symptoms (remission) or low disease activity is achieved. RA flares (relapses) are associated with painful, stiff joints and may occur with treatment withdrawal. Predicting disease flares can determine which patients can benefit the most from treatment withdrawal.

MRI is a medical imaging technique that has been used to assess joint damage severity and inflammation in patients with RA. Abatacept is a biological drug that reduces inflammation and alters the function of cells responsible for inflammation. A lower DAS28 (CRP) score suggests disease remission. However, it is unknown whether disease flare can be predicted following treatment withdrawal based on MRI findings in patients with DAS28 (CRP)-defined remission at 12 months.

This study included 172 patients with DAS28 (CRP)-defined remission withdrawal from three RA treatments. 70 patients had received abatacept with MTX. 49 patients were given abatacept only. 53 patients received MTX alone. Patients were assessed based on C-reactive protein (CRP; an inflammation blood marker), DAS28(CRP), Health Assessment Questionnaire-Disability Index (HAQ-DI score), pain, Patient Global Assessment, MRI synovitis, erosion, bone edema, and combined inflammation scores.

After 6 months of treatment withdrawal, 58% of patients had a disease flare. After 12 months, 66% of patients had a flare. Potential predictors of flare at withdrawal were higher HAQ-DI, MRI synovitis (inflammation of the joint), erosion, bone edema, and combined inflammation scores. After 6 months of treatment withdrawal, high HAQ-DI was an independent flare predictor. After 12 months of treatment withdrawal, high MRI erosion scores were independent flare predictors.

The study found that HAQ-DI and MRI measures of bone damage may identify patients with early RA in clinical remission that are likely to have successful treatment withdrawal.

The study included a relatively small number of patients with RA from a larger population, so generalizations cannot be made. Flare was not clearly defined in the study. Further studies are needed.