medwireNews: Dose reduction of biologic DMARDs is possible in approximately two-thirds of rheumatoid arthritis (RA) patients in stable remission, results of a Danish real-world study suggest.
However, Cecilie Heegaard Brahe (Rigshospitalet, Copenhagen) and co-researchers stress that “[o]nly a few RA patients in sustained remission could discontinue [biologic] DMARD” use altogether.
The team investigated the success of biologic tapering in 141 patients following the implementation of a guideline for mandatory tapering of all biologic DMARDs for RA patients in stable remission, defined as a Disease Activity Score at 28 joints based on C-reactive protein (DAS28-CRP) of no more than 2.6 points for at least 1 year. The majority (91%) of patients were receiving tumor necrosis factor inhibitors, most commonly adalimumab, and 80% were taking conventional DMARDs alongside biologic treatment.
According to the ADOPT guideline – established in the Capital Region of Denmark between 2013 and 2015 – biologics were tapered in a stepwise manner to two-thirds of the standard dose at baseline, to half the standard dose at week 16, and discontinued at week 32 if patients were still in remission. For patients who experienced flares, the dose was escalated back to the previous step and not tapered again.
As reported in Rheumatology, 62% of patients successfully tapered their biologic treatment during 2 years of follow-up. A total of 18% received two-thirds of their standard biologic dose, while 28% tapered to half the dose, and 16% stopped taking biologics.
The median DAS28-CRP score increased by 0.1 points from baseline to the 2-year follow-up, while the modified total Sharp/van der Heijde score (mTSS) increased by an average of 0.01 points, and 7% of patients experienced radiographic progression (change in mTSS>1.2 points).
Heegaard Brahe and colleagues note that radiographic progression was significantly more common in patients who remained on their full dose of biologic at 2 years compared with those who tapered successfully (17 vs 1%), and progression did not occur among those who stopped biologic treatment altogether, suggesting “that it was the patients with less severe disease that could be tapered or withdrawn successfully.”
The researchers also analyzed predictors of tapering success, finding that male sex, a smaller number of prior biologic DMARDs, and a lower combined magnetic resonance imaging (MRI) damage score were associated with a greater likelihood of successful tapering.
And in an exploratory prediction model, a male patient with no more than one previous DMARD and low MRI scores for inflammation and damage had a 95% likelihood of successful tapering, while a female patient with at least two previous biologics and high MRI scores had only a 14% chance, say the study authors.
They caution, however, that these findings “should be validated in other cohorts.”
medwireNews is an independent medical news service provided by Springer Healthcare. © 2018 Springer Healthcare part of the Springer Nature group
- Depressive symptoms linked to flare risk after tapering TNF inhibitors in RA patients
- Tapering biologics associated with worsening QoL
- CRP levels could help guide tapering of biologics in RA patients
- Discontinuing biologic treatment may lead to loss of remission in RA patients
- Dose reduction of TNF inhibitors a ‘reasonable long-term approach’ for RA patients