How to Taper Biologics and Manage Remission in RA

August 3, 2016

Tapering DMARDs, predicting risk for relapse from RA remission and managing remission, are issues covered in this review published in ARD.

A rheumatoid arthritis diagnosis 30 years ago usually meant lifelong suffering from crippling joint damage. But today, disease-modifying anti-rheumatic drugs (DMARDs), both synthetic and biologic, can send the disease into remission. In one study, for example, after one year of discontinuing infliximab, 70 percent of patients continued to have a positive clinical response. A Norwegian study showed that 40 percent of RA patients in general achieved remission.

Infliximab and other biologics can lead to sustained remission in some patients with rheumatoid arthritis (RA), which presents an interesting question:  What is the optimal management strategy for RA patients in remission?

A review article published in the June 3 issue of the Annals of the Rheumatic Diseases examines when tapering or discontinuing DMARDs should be considered in rheumatoid arthritis.  [[{"type":"media","view_mode":"media_crop","fid":"50693","attributes":{"alt":"©KPG_Payless/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_3367910294285","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6207","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©KPG_Payless/Shutterstock.com","typeof":"foaf:Image"}}]]

“If we in the future want to investigate the possibility of curing RA and develop treatment strategies to reach a cure, we will need to consider structured DMARD tapering to address this concept,” writes Georg Schett of the University of Erlangen-Nuremberg in Germany, and colleagues in the review.

3)      Simplified disease activity index (SDAI) <3.3

4)      Clinical Disease Activity Index <2.8

5)      The American Colleague of Rheumatology (ACR)/European League Against Rheumatism  (EULAR) recommend a sustained remission of at least six months.

6)      And once tapering has begun, use stable DMARD treatment with respect to type and dose of DMARDs over the last 6 months.

7)      Do not use glucocorticoids to maintain remission state (Exception:  stable doses of low-dose glucocorticoids (≤5 mg prednisolone per day).

 

 

 

 

 

 

 

 

 

 

 

 

 

1)      Anti-citrullinated autoantibody negativity and the presence of deep remission, such as absence of ultrasound synovitis or normal serum markers of inflammation, are associated with higher chances to achieve drug-free remission.

2)      Disease relapses occur more often in patients starting TNF inhibitors late in their disease course.

 

 

 

 

The authors of the review suggest that a gradual withdrawal with an initial dose tapering phase, may be preferred over immediate withdrawal for both biological and synthetic DMARDs.

 

 

1)      Monitoring should be planned and conducted regularly to detect relapses as early as possible.

2)      Patient education is essential - specifically about the risks of relapse and how to manage a relapse.

3)      Most studies show that reintroducing the patient’s former DMARD regimen will recapture remission.

 

 

 

 

 

 

 

 

 

 

 

 

 

References:

Gyorgy Nagy and Ronald F van Vollenhoven. "Sustained biologic-free and drug-free remission in rheumatoid arthritis, where are we now?" Arthritis Research and Therapy. Aug. 3, 2015. DOI: 10.1186/s13075-015-0707-1

Aga AB, Lie E, Uhlig T, et al. “Time trends in disease activity, response and remission rates in rheumatoid arthritis during the past decade: results from the NOR-DMARD study 2000–2010.” Ann Rheum Dis 2015;74:381–8.

Georg Schett, Paul Emery,  et al. “Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions,” Ann Rheum Dis 2016;75:1428–1437.  DOI:10.1136/annrheumdis-2016-209201