Psoriatic Arthritis Likely to Return Without Meds
Disease often recurs when people in remission stop their medications.
Psoriatic arthritis patients who stop their medication because their disease is in remission are likely to experience a rapid recurrence, according to a small study published online recently in the journal BMJ.
Psoriatic arthritis (PsA) – a form of inflammatory arthritis related to the skin condition psoriasis that affects both skin and joints – is often treated with conventional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, and biologic drugs, primarily tumor necrosis factor (TNF) inhibitors such as etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade) and golimumab (Simponi). These drugs help keep the disease under control. In some cases, they can even lead to a disappearance of symptoms, prompting patients to wonder if they still need their medication.
The new study suggests they do.
For the study, researchers at the University of Erlangen-Nuremberg in Germany looked at 26 people with PsA whose disease was in remission (with no musculoskeletal complaints and minimal or no skin symptoms) for at least six months and who were being treated with either a conventional DMARD or a TNF inhibitor. The patients were taken off their medication and monitored for six months. If a doctor confirmed a disease flare, the medication was restarted right away.
Twenty of the 26 patients developed doctor-confirmed symptoms again within the study period. On average, symptoms recurred within 74.5 days (about 3 ½ months). The study found no difference in recurrence rates between patients who had been taking methotrexate and those who had been taking a TNF inhibitor. Women were more likely than men to stay in remission, and people who had had the disease for a longer time and those who had more severe skin symptoms were less likely to stay in remission.
Lead study author Georg Schett, MD, professor of medicine, says he was “very much” surprised at the high rate of recurrence. The results mean “that we rarely cure PsA with current treatment but rather, effectively suppress inflammation and hence signs and symptoms,” says Dr. Schett.
Soumya Reddy, MD, was surprised mainly by the speed of recurrence. “It happened pretty rapidly,” says Dr. Reddy, assistant professor of medicine at New York University Langone Medical Center and co-director of its Psoriasis and Psoriatic Arthritis Center. According to conventional wisdom, patients are likely to relapse “somewhere within a few months to 18 months” after going off medication.
“In this study, they’re seeing that about 75 percent recurred within the six months and most of them within the first two to three months. I think this reflects clinically what we see; usually the disease does come back within several months to some degree,” she says.
Even when symptoms stay at bay for a longer period, symptoms can still return, says Dr. Reddy. “We’ve all seen patients who’ve had no disease for five years and then it recurs after five years.”
The researchers say it appears that though the disease may quiet down during remission, it doesn’t cease to exist. “A very interesting and stunning finding was the fact that the distribution of joint disease at the time of flare followed its original distribution, suggesting a kind of tissue memory,” Dr. Schett notes.
The study authors hypothesize that starting treatment for PsA as early as possible could, in theory, make the disease more curable and lasting remission more likely. “The observation that longer disease duration and synovial hypertrophy [thickening of the joint lining, a sign of chronic inflammation in the joints] by ultrasound are more often associated with the recurrence of PsA suggests that joint damage in conjunction with inflammation may prime these joints for disease and enhance their susceptibility to become affected again. Such concept would further strengthen the importance of early intervention in PsA,” they write.
The study looked at patients who had had the disease for a long time. “These are the types of patients that we see – patients who have had disease for many years, and they’re well controlled on either methotrexate, a combination of methotrexate and a biologic, or just a biologic,” says Dr. Reddy. “If you looked at patients who had shorter disease duration, would the outcome be different? Or if you had patients who had less severe disease? That might be something to look at.”
The results are not relevant to rheumatoid arthritis, notes Dr. Schett, since that disease “is fundamentally different” from PsA, but they could potentially have implications for spondyloarthritis – a type of arthritis that usually affects the spine – “as there are shared pathophysiological concepts.”
Although some PsA patients may be frustrated by the need to stay on medication, remission is far better than no remission. “Sometimes after four years, you forget how you felt before, how affected your joints and your skin were, prior to being on the medications,” says Dr. Reddy. “The fact that you see the patient assessment scores worsening so rapidly [after stopping medication] also proves to the patients when they stop the medication that the medication really was doing something dramatic for them.”