Tapering of Biological DMARDs for RA Found to Be Feasible in Daily Practice

The tapering of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) who have achieved low disease activity or remission is feasible in daily practice, according to retrospective study data published in Arthritis Research & Therapy.

Investigators conducted a retrospective study of patients with RA who received treatment at the Brussels UCLouvain clinic in Belgium between 2000 and 2018. The demographic and clinical characteristics of patients treated with a reduced bDMARD dose were compared with patients who remained on a stable dose. Relevant characteristics included age at diagnosis, age at current therapy initiation, smoking status, disease activity, patient-reported health, number of painful or swollen joints, and C-reactive protein levels. Investigators also assessed which bDMARDs were most suitable for dose reduction. For each bDMARD, the annual cost per patient was calculated for reduced and full doses.  

Data from 332 patients with RA were analyzed. Overall, 140 patients (42.1%) received a tapered regimen and 192 (57.9%) received a stable dose. Over a mean follow-up period of 14.6 years, 125 patients on a reduced dose were able to maintain their regimen, while 15 experienced relapse that necessitated a change in bDMARD schedule. Patients in the reduced-dose group had a significantly greater mean age at RA diagnosis than patients in the stable-dose group (43.1 vs 38.7 years; P =.04) and were more likely to be rheumatoid factor (RF)-positive (83.3% vs 72.9%; P =.04). Patients in the reduced-dose group also had a lower mean Health Assessment Questionnaire score (1.3 vs 1.5; P =.048) and shorter disease duration at the time of bDMARD introduction (9.7 vs 12.1 years; P =.034) compared with patients who received a stable bDMARD dose.

A greater percentage of patients in the tapered dose group were receiving concurrent methotrexate than in the stable-dose group (86.7% vs 73.8%; P =.005). The most commonly prescribed medications were anti-tumor necrosis factor agents (68%). Adalimumab, etanercept, and rituximab were the most common bDMARDs in the reduced-dose group. For each of these drugs, dose tapering was associated with significant cost reduction. Of 140 patients in the reduced-dose group, 11 were able to reduce their dose by >50%, 39 by exactly 50%, and 75 by <50%.

“In daily practice, clinicians, patients and payers are interested in determining in which bDMARD dose reduction is more likely to be successful,” wrote the investigators. “Our data indicate that [etanercept] and [adalimumab] are the drugs best suited for dose reduction after [low disease activity] or remission status is achieved. This could be explained by the large number of patients treated with these drugs as well as a longer follow-up.” Combination with methotrexate may also increase the likelihood of dose-tapering success.

“Other bDMARDs…could also potentially be reduced but to a lesser extent. The success of the reduction in dose in some bDMARDs is potentially explained by the half-life of the treatment and the recorded dose,” the researcher added. As study limitations, they noted the retrospective study design and the possible confounding effects of disease severity.

Prospective analysis using national registers is necessary to confirm these findings.  

Reference

Dierckx S, Sokolova T, Lauwerys BR, et al. Tapering of biological antirheumatic drugs in rheumatoid arthritis patients is achievable and cost-effective in daily clinical practice: data from the Brussels UCLouvain RA Cohort. Arthritis Res Ther. 2020;22(1):96.