Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, Kings' College London, Great Maze Pond, London, SE1 1UL, UK.
Clin Exp Rheumatol. 2013 Jul-Aug;31(4 Suppl 78):S4-8. Epub 2013 Oct 3.
When rheumatoid arthritis (RA) patients have achieved sustained good clinical responses can their disease-modifying anti-rheumatic drugs (DMARDs) be reduced or discontinued? This review addresses this question by summarising the clinical evidence about DMARD withdrawal. It includes an assessment of predictive factors for sustained DMARD-free remissions.
We evaluated the evidence for discontinuing DMARDs in stable RA in both randomised controlled trials (RCTs) and observational studies.
Six RCTs evaluated DMARD monotherapy withdrawal in 501 RA patients with good clinical responses. Flares occurred in 43/248 (17%) patients who continued DMARD monotherapy and in 117/253 (46%) patients who discontinued DMARDs. Individuals in whom DMARDs were withdrawn were three times more likely to have flares. Restarting DMARDs post-flare was usually successful. Four RCTs evaluated step-down DMARD combinations in comparison to DMARD monotherapy. Patients achieved good clinical responses with combination DMARDs, which were maintained after treatment was tapered to DMARD monotherapy. Four observational studies of tapering or stopping DMARDs in patients with sustained low disease activity states provided supportive evidence for discontinuing DMARDs in some patients. Flares during drug-free remissions were predicted by rheumatoid factor and anti-citrullinated protein antibody status.
Drug-free remission is achievable in some RA patients. Discontinuation of DMARDs after patients achieve sustained remissions results in flares in many patients, which can usually be reversed by restarting DMARDs. Step-down DMARD combinations are effective and achieve sustained responses. Further research is required to establish predictors of drug-free remission; these will identify individuals most likely to benefit or experience disease flares after discontinuing DMARDs.
当类风湿关节炎 (RA) 患者获得持续良好的临床缓解时，是否可以减少或停用其改善病情的抗风湿药物 (DMARDs)？本综述通过总结关于 DMARD 停药的临床证据来回答这个问题。它包括对持续无 DMARD 缓解的预测因素的评估。
我们评估了在稳定的 RA 中停止 DMARD 治疗的随机对照试验 (RCT) 和观察性研究中的证据。
6 项 RCT 评估了 501 例临床缓解良好的 RA 患者 DMARD 单药停药。继续 DMARD 单药治疗的 248 例患者中有 43 例（17%）出现复发，而停用 DMARD 的 253 例患者中有 117 例（46%）出现复发。停药后发生复发的患者复发的可能性是继续 DMARD 单药治疗的患者的三倍。在复发后重新开始 DMARD 治疗通常是成功的。4 项 RCT 评估了 DMARD 联合方案与 DMARD 单药治疗的疗效。患者使用联合 DMARD 达到良好的临床缓解，在减少 DMARD 治疗至 DMARD 单药治疗后仍能维持缓解。4 项关于在持续低疾病活动状态下逐渐减少或停止 DMARD 治疗的观察性研究为一些患者停止 DMARD 治疗提供了支持性证据。在无药物缓解期间发生复发的预测因素是类风湿因子和抗瓜氨酸化蛋白抗体状态。
在一些 RA 患者中可以实现无药物缓解。在患者获得持续缓解后停止 DMARD 治疗会导致许多患者出现复发，但通常可以通过重新开始 DMARD 治疗来逆转。减少 DMARD 治疗方案是有效的，并能实现持续缓解。需要进一步研究以确定无药物缓解的预测因素；这些将确定最有可能在停止 DMARD 治疗后受益或出现疾病复发的个体。
