Rheumatoid Arthritis treatment: Can we use biologic DMARDs early then take them away?

Another one’s here!

I recently wrote about a strategy trial using Etanercept very early in the treatment of rheumatoid arthritis followed by withdrawal of the drug (Read "Can we use TNF inhibitors early then take them away?").

This was a much anticipated trial providing insights which will help us use biologic DMARDs more strategically.

Well, we now have another similar strategy trial published.

This time using a biologic DMARD with a different mode of action, Abatacept. Abatacept is a fusion protein of cytotoxic T lymphocyte-associated antigen-4 and immunoglobulin G1. It selectively modulates a signal required for full T-cell activation (Etanercept by way of comparison, is a TNF inhibitor).

Here is the link to the journal article: the AVERT study.

As a brief summary:

• The patients recruited had early disease (a mean symptom duration of 0.56 years). They had a high inflammatory burden (a mean swollen joint count of 11.1 and a mean CRP of 17.5 mg/L), as well as poor prognostic factors (all had positive anti-CCP with 95% also having a positive RF).
• Patients were randomised to Abatacept /Methotrexate (MTX) in combination vs Abatacept alone vs MTX alone.
• At month 12, the proportion of patients in these 3 groups achieving DAS28<2.6 (Disease activity score-defined remission) were 60.9% vs 42.5% vs 45.2%.
• These patients who achieved DAS28 remission then had their treatment stopped rapidly! Abatacept was withdrawn immediately and MTX (as well as any corticosteroids used) tapered over 1 month.
• At month 18, 6 months after withdrawal of therapy, 24.7% vs 28% vs 17% remained in DAS-defined remission.

These are encouraging results given the group of patients would be considered “difficult” as they had highly active disease at baseline with poor prognostic factors.

A durable remission following withdrawal of medication remains a holy grail in early rheumatoid arthritis. This trial seems another nice step towards this.