Tapering, Discontinuing Glucocorticoids in Patients With RA Receiving csDMARDs

In patients in whom glucocorticoids (GC) are newly initiated along with concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), GC may be reasonably discontinued in a real-life setting when disease activity is shown to be favorable. Data from the longitudinal, observational Treat-to-TARget in RA (TARRA) cohort study, which enrolled patients with rheumatoid arthritis (RA) from Peking University First Hospital in Beijing, China, were used in the current study. Results of the analysis were published in Annals of the Rheumatic Diseases.

The researchers sought to unravel the dynamical trajectory and characteristics of GC tapering and discontinuation in patients with RA who initiated GC with concurrent csDMARDs. They evaluated changes in GC dose and disease activity. In addition, they analyzed patients’ relapse profile within 6 months of GC discontinuation. Data from all eligible participants were collected from the time of initiating GC therapy to December 2020. In the current real-world study, a patient who never received DMARDs or received DMARDs for less than 3 months at the commencement of GC was considered treatment-naïve.

A total of 207 consecutive patients with RA, who contributed 2409 clinic visits, were included in the study. During a median follow-up period of 38.6 months, 124 participants discontinued GC. Patients’ median prednisolone dose of 10 mg/day (range, 5 to 10 mg/day) was decreased by 50% in the first 6 months, then more slowly to 0% by 48 months.

Results of the study showed that the cumulative probability of GC discontinuation was 9.7% at 6 months, 26.6% at 1 year, 48.0% at 2 years, and 58.6% at 3 years. The calculated median time to GC cessation was 27.0 months (range, 19.2 to 34.8 months). Of the 124 participants who discontinued GC, the median time to GC withdrawal was 13.6 months (range, 8.0 to 24.6 months).

Of the 207 participants, 110 were DMARD-naïve and 97 of them were DMARD-experienced. During follow-up, 41 patients in the DMARD-naïve arm and 42 patients in the DMARD-experienced arm discontinued GC. In DMARD-naïve participants, the cumulative probabilities of GC discontinuation were 12.7%, 30.0%, 50.9%, and 60.0% at 6 months, 1 year, 2 years, and 3 years, respectively, with a median time to GC cessation of 24 months. In contrast, in DMARD-experienced participants, the cumulative probabilities of GC discontinuation were 6.2%, 22.7%, 44.7%, and 56.5%, respectively, with a median time to GC cessation of 32 months. Although there was no statistically significant difference observed between the 2 arms (P =.621), apparently faster GC discontinuation was seen in DMARD-naïve individuals.

Of the 124 participants who discontinued GC, 28.2% reported the addition of new csDMARDs or concomitant csDMARDs after 3 months of GC initiation. Among the 124 patients who discontinued GC, the median disease activity score based on 28-jont count (DAS28) dramatically declined from 4.76 at the time of GC initiation to 2.51 at the time of GC withdrawal (P <.001). A similar trend was also observed in simplified disease activity index (SDAI), clinical disease activity index (CDAI), and each individual component (P <.0001).

Approximately half of the 124 patients who discontinued GC were in clinical remission at the time of GC cessation. Within 6 months of GC withdrawal, 79.1% of the participants remained relapse-free.

The investigators concluded that although GC can be feasibly discontinued in a real-life setting in which disease activity is favorable—mostly without any short-term flare being experienced—the withdrawal time is far from achieving the recommended time frame, thus indicating the gap between real-world practice and current guidelines.

Reference

Xie W, Huang H, Li G, et al. Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Ann Rheum Dis. Published online April 2, 2021. doi:10.1136/annrheumdis-2021-220112