Why Your RA Went Into Remission, but Relapsed
There is no cure for rheumatoid arthritis, but remission (no visible signs or symptoms) is possible. Learn why symptoms return and what you can do about it.
Many people with rheumatoid arthritis (RA) can silence their symptoms and halt progression of the disease thanks to biologics, targeted DMARDs and more aggressive treatment approaches. Yet some patients who achieve remission struggle to sustain it.
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 have only an occasional flare of joint tenderness or morning stiffness. The American College of Rheumatology has published criteria for defining RA remission. Regardless of how remission is defined, the signs of relapse are usually clear: 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 maintain remission or quickly recover if you have a setback.
Stopping Medication Can Trigger Relapse
One reason you may have a remission relapse is simple: you stop taking your medications. When an RA patient achieves remission, some doctors will taper treatment, either by decreasing the dose of medication or increasing the time between treatments. 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 medications.
However, 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.
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 aren’t in total remission, are not candidates for the “cold turkey” approach, stresses Dr. Field. The risk of relapse and a worsening of symptoms is 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 on a drug,” says John Hardin, MD, 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. Normally, antibodies protect you from germs and other harmful substances that enter the body. However, scientists now know that some patients start producing antibodies that block the work of biologic drugs. As the 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. Combining a biologic medication with a disease-modifying anti-rheumatic drug (DMARD) such as methotrexate or azathioprine significantly reduces the risk of developing blocking antibodies, according to a scientific review published in JAMA Internal Medicine in 2013.
Alternating Remission and Relapse
About one-third of people 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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