Disease-modifying antirheumatic drug–free remission in psoriatic arthritis: is it attainable and sustainable? A large longitudinal study

According to current management guidelines for psoriatic arthritis (PsA) tapering of disease-modifying antirheumatic drugs (DMARDs) can be considered. However, limited data are available on complete DMARD cessation, also known as disease-modifying antirheumatic drug-free remission (DFR). Therefore, our aim was to investigate whether DFR is achievable and sustainable in PsA and to evaluate possible predictors for sustained disease-modifying antirheumatic drug-free remission (SDFR). From the Dutch southwest Early Psoriatic Arthritis cohort, all newly diagnosed patients with oligoarticular/polyarticular PsA who were treated with DMARDs were included (n = 451). Prevalence of (S)DFR and flare rates (early and late) were described. DFR was defined as the absence of clinical synovitis for ≥3 months after DMARD cessation, while for SDFR, a period of >1 year was used. Early and late flares were defined as restarting DMARD treatment ≤1 and >1 year after DMARD cessation, respectively. Subsequently, possible predictors for true SDFR, that is, SDFR without flaring were explored. After a median of 5.1 years (IQR, 3.0-7.3 years), 22% of patients with PsA had reached DFR, and after reaching DFR, 4.7% had an early flare. Thus, SDFR was achieved in 14.4% of patients with PsA; 5.3% experienced a late flare, which occurred a median of 1.7 years (IQR, 1.4-2.8 years) after DMARD cessation. Eventually, 9.1% of patients reached true SDFR. Low baseline Disease Activity Index in Psoriatic Arthritis and never using biological or targeted synthetic DMARDs were independent predictors for true SDFR. At the time of true SDFR, the Health Assessment Questionnaire was similar to the general population (median, 0.12; IQR, 0-0.75). DFR is attainable in oligoarticular/polyarticular PsA and is sustainable in 9% of patients. However, the subgroup of patients with PsA with high disease activity at baseline and who require biological or targeted synthetic DMARDs do not achieve true SDFR. To our knowledge, this is the first study to demonstrate that chronicity can potentially be influenced in a proportion of patients with PsA.