CRESPA at ten years: treating within 12 weeks, and stopping

Design

Ten-year observational follow-up of a randomised remission-induction trial

Population

49 of 60 original CRESPA patients with early peripheral spondyloarthritis (symptoms ≤12 weeks), mean 10.5 years

Primary outcome

Clinical and drug-free remission at 10 years

Effect

Clinical remission 81.6% (40/49); drug-free remission 30.6% overall and 48.1% without psoriasis (OR 9.1, 95% CI 1.8 to 50)

The original CRESPA trial randomised 60 patients with peripheral spondyloarthritis, all within 12 weeks of symptom onset, to golimumab or placebo. Forty-nine returned for standardised assessment a mean of 10.5 years later.

Eighty-two per cent were in clinical remission — no swollen joints, no enthesitis, no dactylitis — and 30.6 per cent were in longstanding drug-free remission. Among those without psoriasis at baseline, 48.1 per cent were off all treatment, with an odds ratio of 9.1 against those with psoriasis. Quality of life and physical function were better in those in remission. Sex, age, HLA-B27 status and original treatment allocation predicted nothing.

Two cautions belong with that. This is a descriptive follow-up of a small trial, not a randomised comparison of early against delayed treatment, and 11 of the original 60 were not assessed. But it is the longest look available at what very early intervention in peripheral spondyloarthritis leads to, and the separation by psoriasis status is large enough to shape the conversation about stopping.

• Treat peripheral spondyloarthritis as a condition where time to treatment matters, and expedite the first appointment.
• Raise the possibility of eventual drug-free remission with non-psoriatic patients — nearly half achieved it here.
• Be more cautious about withdrawal in patients with psoriasis.
• Baseline HLA-B27 and sex did not predict outcome; do not use them to set expectations.
• Taper against a defined remission standard — no swollen joints, enthesitis or dactylitis — not against symptoms alone.

Why it matters

It puts stopping treatment on the agenda for a disease usually managed as lifelong.

Don't overread it

A descriptive 10-year follow-up of 49 patients with no untreated comparator group.

The statistics, in plain English

An odds ratio of 9.1 with an interval from 1.8 to 50 is a very large effect estimated very imprecisely: 27 non-psoriatic patients, 13 in drug-free remission, and an upper bound that tells you the sample cannot pin the size down. Note also that this is a single-arm descriptive follow-up — the placebo group received golimumab on flare, so the comparison with untreated early disease does not exist. Eleven of 60 patients were not reassessed, and lost patients in remission studies are rarely lost at random.

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