King's College London

Research from the Department of Inflammation Biology, School of Immunology & Microbial Sciences has shown there is an increased risk of disease flare in Rheumatoid Arthritis (RA) patients who suffer from depression. These results may help physicians make more personalised treatment decisions.

Flares in RA present as acute episodes of pain and inflammation in a patient’s joints. These can be unpredictable and debilitating. Data from a recent trial was analysed to identify if there were any predictors of flare in RA patients with stable disease who reduce (by tapering) their RA therapy.

Tapering treatments

The most effective treatments in RA are biologics, such as tumour necrosis factor (TNF) inhibitors which target the immune system and reduce swelling and inflammation. These agents have revolutionised care in RA. They do however have some disadvantages. There is an associated risk of infections due to their immunosuppressant activity. The drugs cannot be taken orally, and instead must be injected under the skin. Lastly, they are expensive to manufacture and place a high cost on NHS resources.

A clinical trial was set up to examine the impact of slowly reducing the dose of TNF inhibitors for patients who were symptom-free with low disease activity (in RA remission). This trial was titled ‘Optimising Treatment with Tumour Necrosis Factor Inhibitors in Rheumatoid Arthritis’ (OPTTIRA).

The results of OPTTIRA show that tapering of TNF therapy is feasible, safe and effective in selected patients with RA. The study demonstrates that tapering TNF’s by 33% does not increase flares or worsen disability or quality of life, and in some patients stopping biologic therapy may be possible. However future research is required to help understand how to personalise these decisions. 

At present, there are no standardised methods to identify which patients can successfully taper therapy without flaring. A further analysis of this OPTTIRA study was carried out by researcher Dr Katie Bechman to identify if there was a link between a patient’s mental health and the likelihood of flare when tapering.

Rheumatoid Arthritis & Mental Health

Mental health disorders are common in patients with RA. 17% of patients suffer from major depression and up to 50% of patients demonstrate significant depressive symptoms. Poor mental health is associated with pain and fatigue. This has been shown to influence response to treatment when therapy is started at diagnosis of RA. 

Until now, no studies had investigated the impact of mental health on patients who are tapering their RA therapy. The aim of this study was to determine if mental health predicted the likelihood of a disease flare, which might lead to more personalised treatment plans in the future. 

Findings

In the study, 97 patients were to taper their anti-TNF dose by either 33% or 66%. Forty-one patients flared. Patients with disability, fatigue and poor mental health (including depression and anxiety) were more likely to flare. Mental health, defined by the 36-Item Short Form Survey (SF-36) Mental Health (MH) subscale, was the only independent predictor of flare after adjusting for patient’s age, gender, RA disease activity, BMI and whether they reduce their anti-TNF dose by either 33% or 66%. The Mental Health score ranges from 0 to 100, with lower scores indicating more severe depressive symptoms.  With every 10-point decrease in Mental Health score, the risk of flare increases by 19%.

Recommendations

This study found that, after considering all possible confounding elements, worse mental health score was associated with disease flare in RA patients undergoing treatment tapering. To ensure success with treatment tapering, a mental health screen should be carried out. This will help physicians make more personalised treatment decisions in the future.

Read the paper here.