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Joint Bone Spine
Volume 85, n° 6
pages 679-685 (décembre 2018)
Doi : 10.1016/j.jbspin.2018.02.002
accepted : 27 November 2017

Therapeutic strategy for rheumatoid arthritis patients who have achieved remission

Bruno Fautrel a, b,
a Institut Pierre Louis d’épidémiologie et santé publique, université Pierre et Marie Curie–Paris 6, Sorbonne universités, GRC-08 (EEMOIS), 750006 Paris, France 
b Service de rhumatologie, groupe hospitalier Pitié Salpêtrière, Assistance publique–Hôpitaux de Paris, 75013 Paris, France 

Corresponding author at: Service de rhumatologie, groupe hospitalier Pitié Salpêtrière, 83, boulevard de l’Hôpital, 75651 Paris cedex 13, France.Service de rhumatologie, groupe hospitalier Pitié Salpêtrière, 83, boulevard de l’Hôpital, 75651 Paris cedex 13, France.

Once remission or low disease activity (LDA) is attained in established rheumatoid arthritis (RA) patients, attempting disease-modifying anti-rheumatic drug (DMARD) tapering appears to be a viable option to avoid patient overtreatment. Potential benefits include reduction in the treatment burden and the risk of adverse events, although the latter has not been demonstrated convincingly. The feasibility of DMARD discontinuation has been tested in numerous studies or trials. All have revealed a high risk of relapse, ranging from 56%–87% at one year. Although remission/LDA can usually be re-established by re-initiation of the previous treatment, the associated risk appears to be more harmful than beneficial. DMARD tapering, either by dose reduction or by injection spacing, is conceptually more acceptable and two superiority randomized controlled trials (RCTs) comparing half-dose etanercept to full-dose continuation demonstrated no significant difference at one year. By contrast, two equivalence RCTs that tested disease activity-guided dose optimization by progressive etanercept and adalimumab injection spacing versus continuation revealed an increased risk of acute flare. Interestingly, one of these also demonstrated the equivalence of increasing injection spacing and standard of care in terms of recurrent flare and overall disease activity over the 18-month follow-up period. The risk of structural damage progression was minimal or null. Reintroduction of DMARD at the previous dose was associated with remission being achieved in the majority of patients who flared. Tapering strategies that adhere to the Tight Control and Treat-to-Target principles appear to be suitable options for RA patients who have achieved sustained remission or low disease activity.

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Keywords : Rheumatoid arthritis, Remission, Step-down strategy, Treatment tapering, De-escalation, Spacing, Dose reduction, Treatment discontinuation, bDMARD, csDMARD

© 2018  Published by Elsevier Masson SAS.
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