What is the best course of treatment for the inflammatory disease arthritis - rheumatoid arthritis (RA)? With modern treatment, around two out of three people with RA avoid impaired functional capacity. But can the treatment have a price? 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 centre, Espen A. Haavardsholm, senior physician and postdoc, Nina P. Sundlisæter, physician and project manager, Siri Lillegraven and physician and PhD student, Kaja E. Kjørholt. Deacon Home 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 therapists nor patients want a relapse in the form of pain, joint destruction or reduced 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 aim of the study is to study whether it is possible to reduce and possibly end immunosuppressive treatment for patients who are completely or almost symptom-free for a longer period of 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
Over the past twenty years, clinical research has revolutionized the treatment of the autoimmune inflammatory disease. New drugs, but also better strategies for the use of 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 price
Kaja K. Eriksrud Kjørholt and Nina Paulshus Sundlisæter are first authors of the recent publication in the journal Lancet Rheumatology. They have analyzed how 160 patients in remission respond to three different treatment strategies.
The patients used established drugs, mainly methotrexate. They were randomly assigned to either continue immunosuppressive therapy unchanged, halve the dose, or first halve and then stop completely. After three years, 80% of those who maintained stable treatment experienced no worsening of their disease, compared with 57% of those who halved their dose and 38% of those who tapered off and stopped treatment.
- Stable disease control with reduced or no active treatment was therefore achievable for a significant group of patients, while at the same time it contributed 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.
- But with several of those who ended treatment, it became necessary to increase the dose of medication beyond what they originally used when they started the study. Several in this group also needed the drug prednisolone, says Kjørholt.
Among those who had finished treatment, there was also a somewhat lower proportion of patients who were in remission according to the strictest criteria.
- On the X-ray, we also saw that there was an increased tendency for joint changes in those who halved the 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-related and health-economic aspects are often the basis for the desire to reduce immunosuppressive treatment. It may be that you are insecure about possible side effects and it may feel like a burden to take the medication. At the same time, you do not want a flare-up of the disease.
The patient and their therapist should therefore take into account factors related to the disease itself and the patient's work and living situation when choosing a treatment strategy. Until now, there has been a lack of long-term data that could inform this joint election.
Important information for shared decisionmaking
The study does not provide clear answers as to whether the treatment should be reduced or not. Treatment strategies must be decided between doctor and patient. Patients should be well informed about the possible advantages and disadvantages of treatment changes. The results from the study thus make important contributions to such a shared decisionmaking process.
Across the country
Patients from all health regions in Norway have participated, and the study has been carried out in close collaboration between ten rheumatology departments. Both doctors and nurses at these departments have participated actively in the implementation of the study.
About the ARCTIC REWIND study
- Led by doctor/head of the Unit for Clinical Research Siri Lillegraven and professor/head of research/senior physician Espen A. Haavardsholm, Department for Research and Innovation at Diakonhjemmet Hospital
- The ARCTIC REWIND csDMARD study is a randomised, clinical multicentre step-down study in patients with rheumatoid arthritis (arthritis) using conventional synthetic disease-modifying drugs (csDMARDs), mainly 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 sign of activity in their disease 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 in disease activity within 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 financed through research funds from the Research Council of Norway and Health South-East
- The study is part of the activity in 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 frequency of approximately 0.5 to 1.0% in the population
- The disease is characterized by inflammation of joints, especially small and medium-sized joints in the hands and feet, and can, left untreated, cause extensive destruction of joints and loss of physical function
- New drugs and improved use of existing drugs have collectively meant that many patients with rheumatoid arthritis today can achieve so-called remission, i.e. few or no signs of the disease
- There is a lack of long-term data on how best to treat the growing proportion of patients with rheumatoid arthritis who achieve remission
