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Arthritis Today

Why Your RA Went Into Remission, but Relapsed

Most RA patients can achieve remission, but it doesn’t always last. Here’s a look at why -- and what you can do to keep symptoms at bay.

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Many people with rheumatoid arthritis (RA) today can silence their symptoms and halt progression of the disease, thanks to new biologic medications and more aggressive treatment approaches. Yet some patients who achieve remission struggle to sustain it, research shows. In a 2012 study published in Arthritis Research & Therapy, doctors at Brigham and Women’s Hospital in Boston tracked the progress of 394 RA patients from the time their disease went into remission. (The typical patient was 56 and had RA for about eight years.) A year later, half of the patients had relapsed at some point. Researchers checked on the patients after another year and found that only about one quarter of the relapsed patients had returned to a state of remission.

Defining Remission

Remission means different things to different people. To some it’s the total absence of symptoms, while other patients might feel their RA is in remission if they only have an occasional flare of joint tenderness or morning stiffness. The American College of Rheumatology has published specific criteria for defining RA remission. Regardless of how you define remission, there’s little ambiguity when a relapse occurs: symptoms you once had under control return, your quality of life diminishes and damage to your joints could be worsening. Understanding why relapses occur may help you remain in remission once you get there and quickly recover if you have a setback.

Stopping Medication Can Trigger Relapse

One reason that some patients with RA have a remission relapse is simple: They stop taking their medications. However, that’s not necessarily because the patient has become forgetful or has purposely skipped a dose. When an RA patient achieves remission, some doctors will taper treatment, either by decreasing the dose of medication or increasing the time between treatments (such as giving a biologic drug every other week instead of weekly). In other cases, a doctor might decide a patient can attempt to go without any medication at all. The purpose of reducing or eliminating a patient’s medication is to minimize the risk of side effects that accompany today’s powerful new medications.

However, these strategies aren’t right for all patients, and someone who had been in remission can have their symptoms return, explains rheumatologist Theodore Fields, MD, clinical director of the Early Arthritis Initiative in the Inflammatory Arthritis Center at New York City’s Hospital for Special Surgery. “I have some patients who have been off medication for a couple of years and stayed in remission,” says Dr. Fields. But that’s true for only a small number of patients, he’s quick to add. Researchers have attempted to determine more precisely what number of RA patients in remission remain symptom-free after discontinuing biologic therapy, but the handful of studies examining this question have failed to produce a clear answer, according to a 2013 scientific review in Clinical Therapeutics.

What’s more, little is known about which RA patients in remission might be able to go drug-free, although some evidence hints that those who received early and aggressive treatment for the disease might be the best. However, patients who have mild symptoms, but who aren’t in total remission, are definitely not candidates for the “cold turkey” approach, stresses Dr. Field. The risk of relapse and a worsening of symptoms are too great.

Biologics Can Stop Working And Trigger Relapse

Scientists are examining a more confounding question about patients with RA who are in remission and then relapse: Why does it occur in people who are still taking medications?  “That can happen within months or even many years after a patient has been started on a drug,” says Dr. Hardin, who is also a professor of medicine in the division of rheumatology at the Albert Einstein College of Medicine, in the Bronx, New York.

The problem, explains Dr. Hardin, appears to be that some people with RA eventually become resistant to the very biologic medications that allowed them to attain remission. This phenomenon occurs when the body develops antibodies that counteract the benefit of the drug. An antibody is a protein made by the immune system, which is your body’s defense network. Normally, antibodies protect you from germs and other harmful substances that enter the body. However, scientists now know that some patients with RA eventually start producing antibodies that block the work of biologic drugs. That includes the widely used class of medications known as tumor-necrosis factor (TNF) inhibitors such as adalimumab (Humira) and infliximab (Remicade). As a biologic drug becomes less effective, a patient in remission will discover that his or her joint symptoms have returned.

Switching RA Medications May Help

Fortunately, an antibody that dampens the benefits of one biologic drug typically doesn’t target others, notes Dr. Hardin. “Switching to an alternative TNF inhibitor often provides an effective therapy,” he says. Moreover, there’s a critical strategy that can help prevent biologic-blocking antibodies from causing problems in the first place. Combining a biologic medication with a disease-modifying anti-rheumatic drug (DMARD) such as methotrexate or azathioprine—which helps turn down activity in the immune system—significantly reduces the risk of developing blocking antibodies, according to a scientific review published in JAMA Internal Medicine in August 2013. In fact, the package insert for infliximab indicates that the drug should be combined with methotrexate, for this very reason.

Alternating Remission and Relapse

About one-third of patients with RA have alternating periods of remission and relapse no matter what therapy they receive, says Dr. Hardin, although no one knows why this happens. One intriguing, if surprising, theory holds that certain forms of bacteria and other microbes in the human digestive tract may influence the severity of RA. Studies have confirmed that diet and other factors can alter the composition of bacteria in the gut. “A change in that bacterial flora could potentially change activity of the disease in an individual,” says Dr. Hardin. However, this theory is in its infancy, he notes, adding that understanding which RA patients in remission are most at risk for relapse, and why, is a critical and active area of investigation.

See Your Doctor if You Relapse

If you are in remission and joint pain and stiffness start to flare, tell your doctor soon.  “Flares are important,” says Dr. Fields. “They may be telling you that a drug that was initially working is losing its effectiveness.” Seeing your doctor promptly allows him or her to adjust your treatment plan, which can prevent serious damage to your joints and help you feel better.

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