Rheumatoid arthritis (RA) is the most common inflammatory joint disorder. Since twenty year and the use of synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and biological (b)DMARD, remission can be reached. When remission is obtained, the physician has no recommendations for managing a step-down, and future guidelines will be useful to assist the clinician. Recent data suggest that tapering is feasible, but with high risk of flares. Flares are less frequent when bDMARD blood concentration is high. But, the optimal adalimumab concentration to keep before a step of tapering no targeting personal is unknown.
Patient over 18 years of age
Patients with a diagnosis of RA according to ACR/EULAR 2010 criteria
Remission according to DAS28<=2.6 for at least 6 months
ADA 40 mg every two weeks (= every 14 days) according to the standard regimen
Incapacity or refusal to understand and / or sign informed consent to participate in the study.
Existing pregnancy, lactation, or intended pregnancy within the next 15 months
Fibromyalgia associated to RA
Any dose of prednisone for RA treatment 6 months before inclusion
Single group
Clinical tapering strategy
DrugClinical Tapering strategy : Adalimumab injections will be progressively spaced out according to DAS28 assessment every 3 months
Step Wedge trial
DrugStep Wedge trial : At baseline, all the patients will receive in this study the standard adalimumab dosing regimen. At subsequent time points (steps), patients will begin the intervention of interest, here the tapering adalimumab strategy. The time at which a patient begins the intervention will be randomized. We fixed the time steps duration to 3 months that corresponds the frequency of there commended follow-up of RA patients
Rheumatoid arthritis flare-up
The RA flare-up will be defined as previously by: 1. a disease activity score (DAS)28 that increase above 2.6 for patient previously in remission (DAS28≤2.6) and a DAS28 increase (ΔDAS28) of 0.6 or greater for patients with low disease activity (2.6\<DAS28\<3.2) : YES/NO 2. Use of a glucocorticoid for the symptoms of RA, regarless of the DAS28 : YES/NO DAS28 is calculated according to the formula that is composed of the number of tender joints (TJC) and swollen joints (SJC), patient's global assessment of disease activity on a visual analogue scale (PGA, 0-10), and C-reactive protein (CRP). Formula for calculating DAS28 using C-reactive protein (CRP) : DAS28-CRP=(0.56 × √TJC) + (0.28 × √SJC) + (0.014 × PGA \[mm\]) + (0.36 × ln(CRP in mg/L+1) + 0.96,
Infection
Number of infection
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Centre Hospitalier Universitaire de Saint Etienne
Lead sponsor
AAP MESSIDOR
Collaborator
