Getting to Early RA Remission: What Can We Learn from Clinical Trials?


In a comprehensive review of clinical trials, combination therapies with biologics offered better chances of long-term remission than monotherapy with a DMARD.

Bykerk VP, Keystone EC, Kuriya B, et al.Achieving remission in clinical practice: lessons from clinical trial data. Clin Exp Rheumatol (2013) Apr 22, epub ahead of print

A comprehensive review of clinical trials, observational studies, systematic reviews, and abstract data shows that remission in early rheumatoid arthritis (ERA) can be achieved by prompt treatment with disease-modifying anti-rheumatic drug (DMARD) combination therapy or by combination therapy with biologics.

Better responses came from ERA trials that used combination therapies with biologics than with DMARD monotherapy. Those trials also showed less radiographic progression.

The review includes a total of 75 publications (including published clinical trials and ACR and EULAR abstracts from 2000 to 2010), with varying criteria for remission, treatment approaches, and durations of followup. The goal was to determine the frequency of remission among patients with new-onset RA treated within 3 years of diagnosis.

Analysis of 21 ERA clinical trials (encompassing 8,248 patients) revealed clinical remission rates for combination therapies with DMARDs ranging from 9% to 16%, and from 15% to 70% for combination therapies with biologics.

Tight control with pre-specified treatment targets improved clinical remission and other outcomes in ERA, and this along with optimal methotrexate dosing is the first line standard of care worldwide, says the study's lead author Vivian Bykerk, MD of the Hospital for Special Surgery in New York.

The trials defined clinical remission in a variety of ways, using 2011 and earlier ACR and EULAR criteria, including ACR core set measures or cut-point thresholds for composite indices, Disease Activity Score (DAS), Simplified Disease Activity Index (SDAI) or Clinical Disease Activity Index (CDAI).

The review points up the impact of such inconsistent definitions, and concludes that the added stringency of the 2011 criteria may increase the proportion of patients achieving true remission. Identifying predictors of sustained remission may also allow customization of treatments in ways that achieve better radiographic and functional outcomes, the authors add.

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