What is the best course of treatment for the inflammatory arthritis disease rheumatoid arthritis (RA)? With modern treatment, around two out of three people with RA avoid impaired functional capacity. But can treatment come at a cost? A recently published research article in The Lancet Rheumatology provides new insights into different treatment strategies.
New knowledge about arthritis has been researched at Diakonhjemmet Hospital. From left, head of the REMEDY center, Espen A. Haavardsholm, consultant and postdoc, Nina P. Sundlisæter, physician and project manager, Siri Lillegraven and physician and PhD fellow, Kaja E. Kjørholt. Diakonhjemmet Hospital, Nicolas Tourrenc
The study is based on the question of whether this patient group needs the same level of medication after achieving good disease control. Neither practitioners nor patients want a relapse in the form of pain, joint destruction or impaired functional ability.
New research data on treatment strategies
The article is based on the ARCTIC REWIND study at the REMEDY Center at Diakonhjemmet Hospital. The study aims to study whether it is possible to reduce and possibly discontinue immunosuppressive treatment for patients who are completely or almost symptom-free for a long time, so-called remission.
“There has previously been a lack of good research data in this area,” says Siri Lillegraven , the study's project manager.
Previously, results from the first and second years of the study have been published in two articles in the prestigious journal JAMA, and there has been excitement about how the patients have fared after three years.
Treatment revolution
Clinical research has revolutionized the treatment of autoimmune inflammatory diseases over the past twenty years. New drugs, but also better strategies for using established drugs, such as methotrexate, have led to more accurate treatment and better disease control.
Disease control without treatment achievable for many – but with potential cost
Kaja K. Eriksrud Kjørholt and Nina Paulshus Sundlisæter are the first authors of the recent publication in the journal Lancet Rheumatology. They analyzed how 160 patients in remission respond to three different treatment strategies.
The patients were taking established drugs, mainly methotrexate. They were randomly assigned to either continue their immunosuppressive therapy unchanged, reduce the dose by half, or first reduce it by half and then stop it altogether. After three years, 80% of those who maintained stable treatment did not experience worsening of their disease, compared with 57% of those who reduced the dose by half and 38% of those who tapered and stopped treatment.
“Stable disease control with reduced or no active treatment was thus achievable for a significant group of patients, while at the same time contributing to a significantly increased risk of flare-ups,” explains Kaja KE Kjørholt. She says that most of those who experienced increased symptoms quickly regained good disease control when they returned to the original immunosuppressive treatment.
– However, in several of those who completed treatment, it was necessary to increase the dose of medication beyond what they were originally using when they started the study. Several in this group also needed the drug prednisolone, says Kjørholt.
Among those who had completed treatment, there was also a somewhat lower proportion of patients who were in remission according to the strictest criteria.
– On X-rays, we also saw that there was a slightly increased tendency for joint changes in those who halved their treatment, says Lillegraven.
She explains that they did not observe increased side effects among those who continued with stable treatment, which suggests that this treatment is generally well tolerated.
Why change effective treatment?
Personal, health and health economic aspects often underlie the desire to reduce immunosuppressive treatment. It may be that one is unsure about possible side effects and it may feel like a burden to take the medications. At the same time, one does not want the disease to flare up.
The patient and their caregiver should therefore take into account factors related to the disease itself and the patient's work and life situation when choosing a treatment strategy. Until now, there has been a lack of long-term data that could inform this combination.
Important information for joint elections
The study does not provide clear answers as to whether treatment should be reduced or not. Treatment strategies must be decided between the doctor and the patient. Patients should be well informed about the possible advantages and disadvantages of treatment changes. The results from the study thus provide important contributions to such a shared decision-making process.
Across the country
Patients from all health regions in Norway have participated, and the study has been conducted in close collaboration between ten rheumatology departments. Both doctors and nurses at these departments have actively participated in the implementation of the study.
About the ARCTIC REWIND study
- Led by physician/head of the Clinical Research Unit Siri Lillegraven and professor/head of research/senior physician Espen A. Haavardsholm, Department of Research and Innovation at Diakonhjemmet Hospital
- The ARCTIC REWIND csDMARD study is a randomized, multicenter clinical tapering study in patients with rheumatoid arthritis (RA) using conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), primarily methotrexate
- The purpose of the study is to investigate the effect of reduced and discontinued treatment with immunosuppressive drugs versus stable treatment in patients with rheumatoid arthritis who have had very little evidence of disease activity for at least a year; the effect of the three different treatment strategies was measured by looking at the proportion of patients who had flare-ups of disease activity over three years
- Involved 10 rheumatology departments from all health regions in Norway – Tromsø, Mo i Rana, Ålesund, Bergen, Kristiansand, Drammen, Lillehammer, Moss, Martina Hansens Hospital, in addition to Diakonhjemmet Hospital in Oslo
- 160 patients participated in the study which is now being published
- The study is funded through research funds from the Research Council of Norway and South-Eastern Health
- The study is part of the activity of the research center REMEDY, https://www.remedy-senter.no
- Read the article, Effects of tapering conventional synthetic disease-modifying antirheumatic drugs to drug-free remission versus stable treatment in rheumatoid arthritis (ARCTIC REWIND): 3-year results from an open-label, randomized controlled, non-inferiority trial
About rheumatoid arthritis
- Rheumatoid arthritis is one of the most common autoimmune diseases, with a prevalence of approximately 0.5 to 1.0% in the population
- The disease is characterized by inflammation of the joints, especially small and medium-sized joints in the hands and feet, and if untreated can cause extensive joint destruction and loss of physical function
- New medications and improved use of existing medications have collectively meant that many patients with rheumatoid arthritis today can achieve so-called remission, meaning few or no signs of the disease
- There is a lack of long-term data on how best to treat the growing proportion of rheumatoid arthritis patients who achieve remission
