Many people with rheumatoid arthritis (RA) today can silence their symptoms and halt progression of the disease, thanks to new biologic medications and more aggressive treatment approaches. Yet some patients who achieve remission struggle to sustain it, research shows. In a 2012 study published in Arthritis Research & Therapy, doctors at Brigham and Women’s Hospital in Boston tracked the progress of 394 RA patients from the time their disease went into remission. (The typical patient was 56 and had RA for about eight years.) A year later, half of the patients had relapsed at some point. Researchers checked on the patients after another year and found that only about one quarter of the relapsed patients had returned to a state of remission.

Defining Remission

Remission means different things to different people. To some it’s the total absence of symptoms, while other patients might feel their RA is in remission if they only have an occasional flare of joint tenderness or morning stiffness. The American College of Rheumatology has published specific criteria for defining RA remission. Regardless of how you define remission, there’s little ambiguity when a relapse occurs: symptoms you once had under control return, your quality of life diminishes and damage to your joints could be worsening. Understanding why relapses occur may help you remain in remission once you get there and quickly recover if you have a setback.

Stopping Medication Can Trigger Relapse

One reason that some patients with RA have a remission relapse is simple: They stop taking their medications. However, that’s not necessarily because the patient has become forgetful or has purposely skipped a dose. When an RA patient achieves remission, some doctors will taper treatment, either by decreasing the dose of medication or increasing the time between treatments (such as giving a biologic drug every other week instead of weekly). In other cases, a doctor might decide a patient can attempt to go without any medication at all. The purpose of reducing or eliminating a patient’s medication is to minimize the risk of side effects that accompany today’s powerful new medications.

However, these strategies aren’t right for all patients, and someone who had been in remission can have their symptoms return, explains rheumatologist Theodore Fields, MD, clinical director of the Early Arthritis Initiative in the Inflammatory Arthritis Center at New York City’s Hospital for Special Surgery. “I have some patients who have been off medication for a couple of years and stayed in remission,” says Dr. Fields. But that’s true for only a small number of patients, he’s quick to add. Researchers have attempted to determine more precisely what number of RA patients in remission remain symptom-free after discontinuing biologic therapy, but the handful of studies examining this question have failed to produce a clear answer, according to a 2013 scientific review in Clinical Therapeutics.

What’s more, little is known about which RA patients in remission might be able to go drug-free, although some evidence hints that those who received early and aggressive treatment for the disease might be the best candidates, says rheumatologist John Hardin, MD, vice president of research for the Arthritis Foundation. However, patients who have mild symptoms, but who aren’t in total remission, are definitely not candidates for the “cold turkey” approach, stresses Dr. Field. The risk of relapse and a worsening of symptoms are too great.