The Management of Rheumatoid Arthritis in Remission
In this podcast, Georg Schett, MD, discusses the results and implications of his team’s recent study examining the tapering or stopping of medication in patients with rheumatoid arthritis who achieve stable remission.
Georg Schett, MD, is the vice president of research at Friedrich-Alexander-Universität in Erlangen, Germany.
Tascilar K, Hagen M, Kleyer A, et al. Treatment tapering and stopping in patients with rheumatoid arthritis in stable remission (RETRO): a multi-centre, randomized, controlled, open-label, phase 3 trial. Lancet Rheumatol. 2021;3(11):e767-e777. https://doi.org/10.1016/S2665-9913(21)00220-4
Leigh Precopio: Hello everyone, and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I’m your moderator, Leigh Precopio, with Consultant360.
Between 5% and 45% of patients with rheumatoid arthritis achieve stable remission. But once in remission, how does the management of these patients change?
The authors of a recent study sought to examine the effects of tapering or stopping medication therapy in patients with rheumatoid arthritis in sustained remission. They found that about half of the patients had maintained remission after reducing medication dosage, indicating that the reduction of antirheumatic drugs is an achievable goal for many.
To learn more about the study results and their implications, Consultant360 reached out to lead study author Georg Schett, MD, who is the vice president of research at Friedrich-Alexander-Universität in Erlangen, Germany.
Thank you for joining me today, Dr Schett. What was the impetus for your study?
Georg Schett, MD: The impetus of our study was that patients using anti-rheumatic therapies are using them usually for a long time. However some of the patients are feeling much better due to their therapy, their so-called remission of disease, in this case, rheumatoid arthritis. They always question the doctor whether they can stop or reduce the therapy or not.
Leigh Precopio: The result of your study indicated that remission was sustained in about half of the patients who reduced their medications. Is this a result that surprised you, or did you anticipate this?
Georg Schett: The idea of this study was to compare continuation of treatment versus reduction of treatment. In the reduction, we actually reduced therapy by 50% in 1 arm, and in the other arm, we did the same. After half a year if they were still doing well we stopped all the treatments. There were 3 arms compared, and obviously, only very few patients relapsed in the continuation arm because they were on stable remission. Usually, when you are on stable remission and you continue the treatment, you are doing well over time.
But what was quite impressive was that not all of or the majority of patients relapsed when they reduced the treatment. That was pretty interesting that about 50% were absolutely fine with reduced therapy, even without therapy, and that was really surprising for us. It shows that some of the patients actually are taking their treatment for nothing because they actually were fine to reduce or even to stop and they haven't flared. What we considered from this data that there can be much more flexibility in the remission state in patients with rheumatoid arthritis.
Leigh Precopio: Did any patient characteristics such as the type of disease-modifying anti-rheumatic drugs patient the patient was taking or severity of the patient's disease activity impact the study results?
Georg Schett: All these patients were in remission. That means that they had usually no swollen joints and not much pain, almost no pain, so they're doing absolutely well. When you ask the patient and you ask them about their rheumatoid arthritis, they will say, "I'm doing well with the disease. There is no disease whatsoever." We also require that this is a very stable situation, that it's at least more than 6 months. On the average, it was about 12 months of remission, so they were really doing well for some time.
When you think of predictors, which patients are actually lapsing more easily - it's auto-antibody positivity. If they have rheumatoid factor or anti-CCP antibodies, they are more likely to relapse. Also, in case they have biological treatment, they're just showing a little bit more resistant disease, their relapse rate was higher.
Also the baseline disease activity. Among these patients, some of them had a little bit of disease, some of them had almost nothing. Those with a little bit of disease, they also had a higher likelihood to relapse. You can see that the study was interesting because it tells the doctor, and also the patient, what is the likelihood to relapse and what are predictors that a relapse might be more likely or not.
Leigh Precopio: What are some clinical pearls that you can give your peers for the close monitoring of disease activity in patients with rheumatoid arthritis who were tapering or stopping medication therapy?
Georg Schett: Well, first, I think it's very important to use therapy and to basically try to reach remission intubation. That's often a challenge. It's of utmost importance to turn down inflammation adequately in rheumatoid arthritis and to keep this state for some time. That's very important. But then, in case this situation is reached, you have some flexibility to reduce treatment, and you should not actually make a very rigid regimen, forever the same therapy, but in stable remission, you can taper. I think it's important to taper, not stop the treatment immediately but to taper it, for instance, by 50%. If the patient is still doing well, after 6 months of tapered therapy, one can try to stop treatment.
It's very important to consult the patients in a way that if they have a relapse, they should tell immediately and there's the possibility to restart therapy. That requires also a little bit of monitoring and coaching of the patient, of course. I think this flexibilization is very well appreciated from the patient's side. We also need experience actually to start the treatment. Even start the treatment to tell the patient, "There is flexibility in it if you reach remission," is actually a very important factor so the patient feels good to start a treatment. Because patients hate to hear that they have to be treated forever with the drug. They want actually to have some flexibility in the treatment regimen. That, I think, can be accomplished based on the data of this study.
Leigh Precopio: What are the next steps for research in this area?
Georg Schett: I think we are still not there to make prediction of relapse, it's still a challenge. We can't predict at the moment each relapse. We can only say there are factors which are associated with a higher likelihood to relapse. To refine this strategy is to filter out patients who might not stop the treatment because the likelihood of relapse is very high, or those who you should actually endorse the reduction on stopping because they have a very good chance to maintain remission even without treatment. That's still a matter of research and an area of error that can be an improvement happen because the more precise you can predict the development of the patient with treatment reduction, the more precise you can consult the patient, of course.
Leigh Precopio: Thank you for your time and for answering my questions today.
Georg Schett: Yes, it was great to talk to you, and I hope that I answered all the questions in the right way and understandable way. I hope that this information will also have some input on your treatment practice and giving actually more flexibility to chronic treatment, which is I think very important for the future.