Remission! Now What?
If your RA is in remission, you may want to take less medication or even a drug holiday.
There is no cure for rheumatoid arthritis (RA), but remission sure feels like one. Today, early and aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) and biologics makes remission more achievable than ever before. But how likely are you to reach remission, and how likely are you to sustain it? And when you reach it, do you stay on your medications or go off of them?
When remission in RA was first defined 1981, it was characterized as elimination of all disease. “That’s a very hard target. We’re more likely to be able to reach limited or small amount of disease,” explains David T. Felson, MD, professor of medicine at Boston University and a practicing rheumatologist.
With that in mind, the medical community created new guidelines in 2011. Representatives of the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed criteria for defining remission so researchers could compare the effectiveness of different treatment regimens. (See “Definitions of Remission” below.)
The Odds of Remission
Because the definition of RA remission has been subjective in the past, published rates vary greatly, ranging from as little as 10% to more than 60%. Certain factors will bring you to the higher end of that range, the most important of which is early diagnosis and aggressive treatment.
“When treated early with DMARDs and biologics, remission rates can exceed 60%,” says Paul Emery, MD, director, Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, United Kingdom, and one of the authors of the ACR/EULAR definition. For people who don’t begin treatment within two years of first symptoms or who don’t start biologics early in the course of disease, remission rates will range from 10% to 33%, as reported in various studies.
Having low disease activity levels at the start of treatment is also a predictor of being able to attain and maintain remission. It makes sense – a less active disease is easier to quiet.
Being a man will slightly increase your chance of remission. A study published in Arthritis Care & Research in 2012 found that men are 38% more likely to achieve and sustain remission during the first two years of having RA than women. But those gender differences don’t last once patients have the disease for more than two years.
Being negative for the disease markers anti-cyclic citrullinated peptide (anti-CCP) antibody, rheumatoid factor and the shared epitope have been associated with a higher chance of realizing remission. In a study published in Rheumatology in 2012, 20% of anti-CCP-negative patients attained and maintained remission, but only 2–5% of the anti-CCP-positive patients maintained remission.
Once remission has been achieved, whether you stop taking your RA medication is up to you and your doctor. Vivian Bykerk, MD, director of the Inflammatory Arthritis Center of Excellence, Hospital for Special Surgery, New York City, makes sure her patients maintain remission-level symptoms for at least one year before reducing their medications.
“Generally I will slowly taper drugs one at a time: first steroids [earlier than one year], then biologics and finally methotrexate,” she says.
Dr. Emery keeps patients in a medicated remission for six months and then slowly reduces the medication dosages. “Remission is attainable for a good number of people – if you get diagnosed early and treated aggressively – but sustaining a drug-free remission for more than a year or so is unlikely,” he says. In the BEST study, published in the Annals of Rheumatic Diseases in 2011, 46% of the patients who achieved remission and stopped taking their medication had to restart therapy after five months.
While complete treatment withdrawal may be effective for a small number of patients, maintaining remission with a reduced-dose regimen, as Dr. Emery indicated, is likely the best option for a majority of people. That’s because the disease may still be active even though signs of it appear to be gone. A 2015 study published in Arthritis Care & Research indicates that inflammation and joint damage may continue even in the absence of pain and apparent swelling. In such cases, magnetic resonance images may reveal underlying inflammation.
Other studies strengthen the case for reducing medication dosage rather than stopping completely. The PRIZE study, published in the New England Journal of Medicine in 2014, analyzed patients with early RA. Significantly more patients who received the reduced-dose DMARD therapy remained in remission than patients who received no therapy after remission was achieved.
The RETRO study, presented at the 2014 ACR meeting, evaluated reducing, discontinuing, or continuing therapy in RA patients with stable, long-lasting remission. The patients that reduced or discontinued treatment were more likely to experience flares than the patients who continued full-dose treatment.
Should You Take a Drug Holiday?
Many doctors favor reducing dosages in hopes of maintaining remission, but taking a drug holiday could be an option.
If you and your doctor decide you are a candidate for a drug holiday – a temporary stoppage of treatment – consider a few factors: the potential effect on your medication eligibility with your insurance company, the effectiveness of the drug when you restart it, and whether underlying joint damage continues even when RA is in remission.
“Patients may have to change to another biologic by their insurer if, for example, the formulary has changed,” says Dr. Bykerk. “Also, if the same biologic is reintroduced, there is a chance that the patient may have developed anti-drug antibodies to the biologic, resulting in a worse response when using it the second time around.”
If you achieve remission, you and your doctor can weigh the benefits and risks of taking a drug-free holiday. During this time, it’s important that your doctor monitors you closely for signs of worsening disease activity or joint damage.
Definitions of Remission in Rheumatoid Arthritis
The ACR and the EULAR developed criteria defining remission in RA in 2011. These criteria are used by scientists when conducting clinical trials. Your rheumatologist may use these or slightly different measures to determine if your disease is in remission:
- One or fewer swollen joints
- One or fewer tender joints
- An assessment by the patient that on a 0–10 scale, arthritis activity is 1 or less
- A blood test showing little or no inflammation in levels of C-reactive protein, a key marker of inflammation
A second definition uses the Simplified Disease Activity Index to measure disease activity. It consists of a sum score of the four measures in the first definition plus a physician assessment.