Tapering of Biologic DMARDs Feasible in RA in Stable Remission

By following a clinical guideline, many patients with rheumatoid arthritis (RA) in sustained remission can successfully taper biologic disease-modifying antirheumatic drugs (bDMARDs), according to the results of a study published in Rheumatology.

Patients were more likely to successfully taper their bDMARDs if they took a maximum of 1 bDMARD, were male, and had low baseline combined MRI inflammation damage scores.

The study included participants with RA who had a sustained 28-joint Disease Activity Score based on C-reactive protein levels (DAS28-CRP) ≤2.6 and no radiographic progression during the previous year (n=141). Participants had their bDMARD dose reduced to two-thirds of their standard dose at baseline. Doses were reduced to one-half at 16 weeks and discontinued after 32 weeks. If participants had a flare (defined as either DAS28-CRP ≥2.6 and a change in DAS28-CRP ≥1.2 from baseline or erosive progression on X-ray or MRI), the researchers stopped tapering the dose and escalated it to the previous dose level.

At the 2-year follow up, 62% (n=87) of participants had successfully tapered bDMARDs. Of these, 18% (n=26) were receiving two-thirds of the standard dose, 38% (n=39) were receiving half of the standard dose, and 16% (n=22) had discontinued their bDMARD.

The mean change in DAS28-CRP from baseline to 2 years was 0.1, and the mean change in Total-Sharp-Score from baseline to 2 years was 0.01. The researchers also observed radiographic progression in 7% (n=9) of participants.

The researchers identified several independent predictors of successful tapering, including ≤1 previous bDMARD (odds ratio [OR], 0.44; 95% CI, 0.26-0.77; P =.004), male gender (OR, 0.36; 95% CI, 0.13-0.97; P =.04), and low baseline MRI combined inflammation score (OR, 0.92; 95% CI, 0.86-0.99; P =.02), and low baseline MRI combined damage score (OR, 0.99; 95% CI, 0.98-1.00; P =.04).

Immunoglobulin M (IgM) rheumatoid factor negativity was the only independent predictor of discontinuation of bDMARDS (OR, 3.29; 95% CI, 1.26-8.58; P =.015).

“In future studies, it may be considered to add an additional step between half dose and discontinuation, as we found that the majority of flares occurred at this step,” the researchers wrote.

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Reference

Brahe CH, Krabbe S, Østergaard M, et al. Dose tapering and discontinuation of biological therapy in rheumatoid arthritis patients in routine care — 2-year outcomes and predictors [published online August 28, 2018]. Rheumatology. doi:10.1093/rheumatology/key244