A first-of-its-kind Belgian study has assessed how using golimumab treatment within three months of peripheral spondyloarthritis symptoms appearing translates to long-term benefits.
The long-term follow-up of a small peripheral spondyloarthritis trial has suggested that early, intensive treatment may increase the likelihood of achieving drug-free remission 10 years down the track.
“To our knowledge, this is the first study to reevaluate patients with pSpA after a 10-year period, providing unique long-term insights into the impact of golimumab remission-induction treatment in very early pSpA,” the researchers wrote in Arthritis & Rheumatology.
“We observed very high percentages (>80%) of clinical remission after 10 years, emphasising the importance of early remission induction for sustained disease control.”
Sixty patients with newly diagnosed pSpA (symptom onset ≤12 weeks before screening) were enrolled in the Clinical Remission in Peripheral Spondyloarthritis (CRESPA) trial between 2012 and 2015. Patients were randomised to receive 50mg of golimumab or placebo every for weeks in a 2:1 fashion for 24 weeks.
Forty-nine of these patients (28 men, mean age 39 years) participated in the current follow-up study, an average of 10.5 years later. Forty were in clinical remission (15 in drug-free remission, with 25 in remission on medication). Of the nine patients who did not achieve clinical remission, seven had painful entheses, one had a swollen proximal interphalangeal joint, and one had synovitis of both knees.
“This effect was most apparent in patients with nonpsoriatic pSpA, of whom nearly half remained in drug-free remission after 10 years, supporting the existence of a window of opportunity for durable drug remission in pSpA,” the researchers noted.
“The most plausible explanation lies in the markedly shorter disease duration at TNFi initiation in the CRESPA study of <12 weeks versus almost eight years in [a comparator study]. One hypothesis is that early TNFi induction therapy induces an immune reset, thereby restoring immune homeostasis and resulting in sustained drug-free remission.”
There were no differences between patients who did and did not achieve clinical remission with respect to characteristics such as age, gender, treatment group, and whether they achieved remission during the original CRESPA trial. However, a greater proportion of patients who achieved remission on medication had psoriasis (58.8%) compared to patients who achieved drug-free remission (13.3%).
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More than two-thirds of patients (69.4%) were treated with DMARDs at the 10-year follow-up. Roughly a third (32.7%) received biologic DMARD monotherapy, 12.2% received methotrexate monotherapy, and 24.5% received a combination of methotrexate and a bDMARD. Of the patients treated with bDMARDs, 75% continued with golimumab treatment, while 17.8% switched to a TNF inhibitor and 7.1% moved to an interleukin-17 inhibitor.
“These findings indicate that golimumab was generally well tolerated and effective in maintaining disease control in patients with PsA and nonpsoriatic pSpA,” the researchers said.
Patients who achieved clinical remission had higher self-reported health utility and physical functioning compared to patients who did not achieve remission as measured by the EuroQoL Five-Dimension Questionnaire utility score (0.90 versus 0.78, where the maximum possible score is 1.0). Seventeen patients achieved a utility score of 1.0, all of whom were in the remission group.
The researchers felt that there would be considerable cost savings associated with achieving drug-free remission, given the hefty price tag that come with bDMARDs.
“It is reasonable to assume that patients who do not use (b)DMARDs require fewer blood tests to monitor toxicity and consult physicians less frequently (or at least not more frequently), which would further contribute to overall health care cost savings,” the researchers wrote.
“Furthermore, drug-related adverse events (and costs thereof) are averted. However, caution is warranted related to these assumptions because there was no control group continuing therapy under similar conditions and resource use was not assessed, precluding a formal economic evaluation.”
Regardless of these limitations, the researchers maintained that using an early induction strategy in pSpA would be beneficial for a “substantial proportion” of patients in the long term, particularly those with nonpsoriatic pSpA.
