Spontaneous, drug-induced, and drug-free remission in peripheral and axial spondyloarthritis

Abstract

In spondyloarthritis (SpA), spontaneous remission is best described in reactive arthritis, a form of peripheral SpA. Prior SpA observational studies suggested that a significant percentage of patients reached spontaneous remission; however, these patients were followed up under older, broader European Spondyloarthropathy Study Group (ESSG) criteria or were not defined by specific criteria. In general, they were mixed populations of peripheral and axial disease, and the subsets were not differentiated when assessing end points such as remission. There are limited data on the natural history of axial SpA, in part because of the evolution of the criteria with the more recently developed Assessment of SpondyloArthritis International Society (ASAS) criteria, including the designation of non-radiographic axial SpA and peripheral SpA. Clinical trials have been conducted with various remission end points including withdrawal of therapy to determine remission maintenance. The following review addresses the potential for remission in axial and peripheral SpA based on the data from both observational studies and clinical trials.

Practice points

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Remission is an attainable treatment target in patients with spondyloarthritis with the majority of data coming from clinical trials in axial spondyloarthritis and observational studies in peripheral spondyloarthritis.
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Drug-induced remission can be achieved in up to a third of the patients with axial spondyloarthritis treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and in up to a half to two-thirds of the patients treated with tumor necrosis factor α inhibitors (TNFi), especially if the treatment is initiated early (within the first 3–5 years of disease).
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Discontinuation of TNFi upon achievement of remission in ankylosing spondylitis leads to disease flare in the majority of patients within 12 months after treatment cessation. Increased drug intervals and/or dose reduction may be an alternative to complete drug discontinuation for patients in remission. The same may be true for patients with non-radiographic axial spondyloarthritis, but more data are needed to confirm this.
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Reactive arthritis as a form of peripheral spondyloarthritis is characterized by a high rate of spontaneous remissions, while data on the use of antibiotics for remission induction in acute and chronic arthritis are controversial.