It is well known that the best outcomes for patients with rheumatoid arthritis (RA) are achieved with a treat-to-target strategy, but recent research has also focused on tapering therapy, especially biologics, in patients who are in prolonged disease remission without synovitis. In the open-label, randomized, noninferiority ARCTIC REWIND trial, Lillegraven and colleagues looked at the effects of tapering tumor necrosis factor inhibitors (TNFi) in 84 patients at different sites in Norway. Patients who had been in remission for a year or more on stable therapy (including TNFi and conventional synthetic disease-modifying antirheumatic drugs [csDMARD]) were included in the study. Of the 43 randomly assigned to tapering TNFi therapy, nearly two-thirds had a flare in 12 months of follow-up, compared with 5% in the stable TNFi group; thus, noninferiority of tapering TNFi was not supported. This study is small and seems to highlight a greater disparity between the two groups than expected from prior studies. Given the stark difference between the two groups, however, caution is advised in tapering TNFi therapy in patients with RA, even those in "deep remission." This information is reassuring in that most patients who flared had a good response to reinstating TNFi therapy, and it is helpful in counseling patients who prefer to try to reduce their medication burden despite the potential for flare.
The impact of chronic steroid use in RA has also received a lot of scrutiny in recent literature due to possible long-term side effects such as bone loss, hyperglycemia, and accelerated atherosclerotic disease. Palmowski and colleagues conducted a pooled analysis of several European randomized trials comparing the use of low-dose glucocorticoids (< 7.5 mg/d prednisone) vs placebo in combination with targeted therapy for RA. Data from over 1100 patients in five trials were analyzed. Over the course of 2 years, participants in both groups had gained weight, more so in the glucocorticoid group compared with the control group (1.8 kg vs 0.7 kg), with negligible effects on blood pressure. While use of moderate and high doses of glucocorticoids is not advisable for the long term, the use of low doses appears to be tolerable, with relatively minor effects on weight and blood pressure.
Given the chronic nature of RA and increasing incidence with age, comorbidities and multimorbidity (two or more comorbidities) are common in patients with RA. Stevens and colleagues used a national claims database to examine the burden of multimorbidity in people with RA and its association with sex and age in two different age groups (18-50 years and older than 51 years). Over 154,000 patients with RA were matched 1:1 to those without. The risk for multimorbidity was higher in women vs men with RA, though the absolute difference in risk was not large. The magnitude of these differences (between women and men, and between those with and without RA) was more pronounced in the younger age group and, as expected, decreased in the older age group. Of note, men with RA, compared with women with RA, had a higher risk for cardiovascular disease, including hypertension, high cholesterol, coronary artery disease, valvular disease, and heart failure. Women with RA had more psychological, neurologic, and comorbid noninflammatory musculoskeletal conditions, such as chronic lower back pain. These differences stress the need for attention to individualized care to improve patients' quality of life and reduce adverse effects on other areas of health.