In patients with rheumatoid arthritis (RA) who have achieved remission or low disease activity (LDA), discontinuation of biologic disease-modifying antirheumatic drugs (bDMARDs) is associated with an increased risk for losing remission or LDA and for radiographic progression. Tapering of bDMARD doses does not increase the risk for relapse (LDA) or radiographic progression, despite an increased risk for losing remission, when compared with continuation of bDMARD therapy, according to the results of a meta-analysis published recently in Annals of the Rheumatic Diseases.
The investigators conducted a systematic literature search through May 2017, selecting controlled clinical trials that compared bDMARD discontinuation/tapering vs continuation in individuals with remitting RA or LDA. The meta-analysis evaluated the risk ratios (RRs) and 95% CIs associated with losing remission or LDA and the risk for radiographic progression after discontinuing or tapering doses of bDMARDs vs continuing initial therapy.
The meta-analysis was conducted on 9 trials that compared bDMARD discontinuation vs continuation and indicated an increased risk for losing remission (RR, 1.97; 95% CI, 1.43-2.73; P <.0001) or LDA (RR, 2.24; 95% CI, 1.52-3.30; P <.0001) and higher risk for radiographic progression (RR, 1.09; 95% CI, 1.02-1.17; P =.01) with discontinuation. The meta-analysis conducted on 11 trials comparing bDMARD tapering vs continuation showed an increased risk for losing remission (RR, 1.23; 95% CI, 1.06-1.42; P =.006) but not for losing LDA (RR, 1.02; 95% CI, 0.85-1.23; P =.81) or for radiographic progression (RR, 1.09; 95% CI, 0.94-1.26; P =.026) with tapering of bDMARDs.
The investigators concluded that because of the high risk for infections associated with use of higher doses of bDMARDs, a dose reduction strategy, in which doses are either lowered or spaced farther apart, may be a reasonable option for patients with RA who are in stable remission or LDA.
Henaux S, Ruyssen-Witrand A, Cantagrel A, et al. Risk of losing remission, low disease activity or radiographic progression in case of bDMARD discontinuation or tapering in rheumatoid arthritis: systematic analysis of the literature and meta-analysis [published online November 29, 2017]. Ann Rheum Dis. doi:10.1136/annrheumdis-2017-212423