Intensive Treatment and Holiday of TNF-inhibitors in RA
Although they are limited studies, after reduction of disease activity to clinical remission or low disease activity in patients with RA by infliximab or adalimumab in combination with MTX, most patients, especially reaching 'deep remission', could successfully have clinical remission without TNF inhibitors for 6 months or 1 year and without radiologic and functional progression of articular destruction.
It is noteworthy that 18% of the patients treated with infliximab successfully achieved drug-free remission in the BeSt study. Thus, because treatment with TNF inhibitors may change or modify the course of disease, a clinical and basic research approach to the 'process-driven disease' of RA is warranted.
The biggest difference of the enrolled patient population in European studies such as the BeSt and OPTIMA and Japanese studies such as RRR and HONOR was disease duration; mean disease duration was 0.2–0.8 years in the former vs. 6– 8 years in the latter, implying that biologic-free remission is possible in not only early RA patients but also in long-established RA and that infliximab and adalimumab may alter the disease course of RA.
Different from European studies such as BeSt and OPTIMA, Japanese studies including RRR and HONOR were initiated and conducted by investigators without supports from pharmaceutical companies, and were partly supported by research grants from the government. Discontinuation of biologics during the treatment of RA has become an important theme and the area of investigation in not only current rheumatology but also patients and governments from the risk–benefit point of view including health–economic considerations. This review may provide an opportunity to discuss the possibility of 'treatment holiday of biologics' from wider standpoints.
Conclusion
Although they are limited studies, after reduction of disease activity to clinical remission or low disease activity in patients with RA by infliximab or adalimumab in combination with MTX, most patients, especially reaching 'deep remission', could successfully have clinical remission without TNF inhibitors for 6 months or 1 year and without radiologic and functional progression of articular destruction.
It is noteworthy that 18% of the patients treated with infliximab successfully achieved drug-free remission in the BeSt study. Thus, because treatment with TNF inhibitors may change or modify the course of disease, a clinical and basic research approach to the 'process-driven disease' of RA is warranted.
The biggest difference of the enrolled patient population in European studies such as the BeSt and OPTIMA and Japanese studies such as RRR and HONOR was disease duration; mean disease duration was 0.2–0.8 years in the former vs. 6– 8 years in the latter, implying that biologic-free remission is possible in not only early RA patients but also in long-established RA and that infliximab and adalimumab may alter the disease course of RA.
Different from European studies such as BeSt and OPTIMA, Japanese studies including RRR and HONOR were initiated and conducted by investigators without supports from pharmaceutical companies, and were partly supported by research grants from the government. Discontinuation of biologics during the treatment of RA has become an important theme and the area of investigation in not only current rheumatology but also patients and governments from the risk–benefit point of view including health–economic considerations. This review may provide an opportunity to discuss the possibility of 'treatment holiday of biologics' from wider standpoints.
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