Patients with RA in Remission – Drug-Free!
In a new study, scientists detail how some adults with highly active early stage RA for whom the future looked pretty poor in terms of joint health are now enjoying an extended period of remission, drug-free. The study is being heralded as the first to show sustained remission in RA after withdrawal of all RA therapy. This means that patients are not taking biologics, methotrexate, or steroids to control their condition.
Known as AVERT, the study was carried out at the University of Leeds in the United Kingdom and involved 351 adults who had been suffering from symptoms of RA for less than two years. The patients all had anti-cyclic citrullinated peptide antibodies, were tested for levels of C-reactive protein above 3.2 (a marker for inflammation) and found to have a disease activity score in 28 joints (DAS28). None of the patients had been previously treated with methotrexate or biologic therapies for RA.
These 351 patients were randomly assigned to one of three groups:
- Combination therapy with abatacept 125 mg plus methotrexate
- Abatacept 125 mg alone
- Methotrexate alone.
After the patients had been treated with one of these three strategies for 12 months those whose disease activity score had dropped below 28 (CRP <3.2) then went onto a 12-month withdrawal phase where all treatment for RA was withdrawn, including the above medications and steroids. During this time 79.4% of patients were once again treated with RA therapy because their symptoms worsened. However, some patients went on to remain in remission, without needing to go back on RA therapy in the next 18-months of the study. The researchers observed that clinical assessments of the patients matched joint changes as seen on MRI scans.
Results of AVERT Study for RA
Those patients in group 1 (combined abatacept and methotrexate) and in group 2 (abatacept alone) had higher rates of drug-free remission than those in the methotrexate monotherapy group; rates were 14.2%, 12.4%, and 7.8%, respectively. Those patients taking abatacept (sold under the brand-name Orencia) who had shorter symptom duration, lower baseline disease activity, or longer sustained DAS remission prior to treatment withdrawal were more likely to remain in remission without having to resume medications.
How Does Abatacept Help Induce Drug-Free Remission in RA?
Although it is not entirely known how these patients are in drug-free remission one proposed mechanism is that abatacept intereferes with the binding of autoantigen-presenting cells to T-cells which means that the body is not induced to attack itself. This may only work when the disease is in its early stages, before a significant bank of immune system cells exist that are programmed to attack joint tissue.
Side Effects of RA Treatment
This research strongly supports the use of abatacept as an initial treatment protocol for adults diagnosed with rheumatoid arthritis, especially as no new safety issues were reported during the study and patient safety was similar in the abatacept group and combination treatment group. Serious adverse events were reported in 6.7% of patients receiving combination therapy, 12.1% of those takin abatacept alone, and 7.8% of those on methotrexate alone. Treatment was discontinued due to adverse effects in 1.7%, 4.3% and 2.6% of patients in these groups, respectively.
Of course, without successful treatment for RA the symptoms of the disease go unchecked and so does degeneration of joints. It may be that some patients respond better to methotrexate than abatacept or vice versa, meaning that physicians are encouraged to begin abatacept therapy early on, potentially helping patients maintain a drug-free remission whereby they have no risk of adverse effects from medications.
European League Against Rheumatism (EULAR) Congress 2014: Abstract OP0026. Presented June 12, 2014.