Drug-Free Remission Unlikely for Psoriatic Arthritis

There is a low chance for psoriatic arthritis (PsA) patients to reach drug free remission, according to findings published in Annals of the Rheumatic Diseases.

Researchers from the University of Erlangen Nuremberg in Germany observed 26 patients (mean age 55 years) for 6 months, of whom 14 were taking methotrexate monotherapy and 12 were taking tumor necrosis factor inhibitors in order to determine if drug free remission in PsA patients was possible in continuous remission. The patients did not have musculoskeletal symptoms and had only minimal skin disease (mean Psoriasis Area Severity Index (PASI): 0.21). If the participants’ symptoms were exacerbated, they were instructed to call their physician — where the symptoms were documented, then the patient was scheduled to be seen within the following 7 days – and restart therapy if appropriate. There needs to be a strategy for advising PsA patients in sustained remission, corresponding author Georg Schett, told MD Magazine in an email.

The researchers found that incidence of disease recurrence was high (occurring in 20 patients) and happened soon after treatment discontinuation, anywhere from about 25 to 75 days after. Male PsA patients were significantly more likely to lose remission, the researchers wrote. Remission was restored in all patients after the re-initiation of disease modifying anti rheumatic drugs (DMARDs).

“We were surprised by the high incidence of disease relapse in PsA patients stopping DMARDs,” Schett wrote to MD Magazine. “Three quarters of the patients relapsed within 6 months despite being in sustained remission at study entry. Moreover, a very similar pattern of disease relapse was observed in PsA patients treated with biologicals and those treated with conventional DMARDs.”

Factors which decreased the likelihood for drug free remission success included long disease duration, more severe skin involvement, and the presence of synovial hypertrophy by ultrasonographic examination at baseline.

“Stopping DMARDs in PsA patients in remission is not a realistic option for rheumatologists because flare rates are very high,” Schett concluded. The authors elaborated by adding the high costs of DMARDs and methotrexate, in combination with the controversial data on their efficacy, raise questions about the necessity of these ongoing treatments.

“Our data do not support that discontinuation of DMARD treatment is a feasible option in patients with PsA, even if in remission for more than 6 months,” the authors concluded in their paper. “Since the duration of remission did not predict the likelihood of recurrence of disease, we do not have data in support of the concept that the susceptibility to develop PsA changes even in cases of long-term remission.”