RheumJC4 Part 2: Tapering Biologics--Why, How, and What If

May 21, 2015

In the second installment of a slide show based on an animated discussion by members of the rheumatology journal club (#rheumjc), partipants focus on the benefits, risks, and realities of tapering biologics in clinical practice.

Part 2 of our slide show summarizing the latest conversation of the Twitter-based rheumatology journal club #rheumjc looks into tapering of biologics for rheumatoid arthritis in actual practice.Three of the participating rheumatologists practice outside the United States, offering a noteworthy difference of perspective.The discussion in Part 1 focused on a randomized trial of biologic tapering published recently in BMJ. Here, participants focused on the clinical realities: Why to taper, whom to taper, when to start tapering, how to decide whether restarting the biologic is warranted, and what happens next.

*van Herwaarden N, van der Maas A, Minten MJ, et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ. 2015;350:h1389. doi: 10.1136/bmj.h1389.

Rheumatologists participating in an online journal club discussing van Herwaarden N, van der Maas A, Minten MJ, et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ. 2015;350:h1389. doi: 10.1136/bmj.h1389.

Why would you even want to taper biologics in rheumatoid arthritis, one participant inquired.

Next, participants in the Twitter-based rheumatology journal club asked when it is appropriate to begin tapering biologics for RA patients in remission.

How to space the tapering of rheumatoid arthritis medications? Patients may take this matter out of your hands.

A digression about triple therapy for rheumatoid arthritis. Tapering may not be the only option. *O'Dell JR, Mikuls TR, Taylor TH et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013 Jul 25;369(4):307-18. doi: 10.1056/NEJMoa1303006. Epub 2013 Jun 11.

Next question: In what order should you taper biologics for RA patients on remission? DMARDs first? Or biologics, then DMARDs?

So you've successfully tapered biologic medication for your rheumatoid arthritis patient. Then there's a flare. What do you do?

The RA patient has flared after you tapered or discontinued a biologic medication. If you resume treatment, what are the odds it will work?

European participants in the #rheumjc discussion about tapering of biologics sense skepticism from their American peers, and attempt to dispel it.

Is it possible to predict which patients will succeed with tapering? This question prompts a lengthy dialogue. The STARA trial referenced by one participant: Stopping Anti-Tumor Necrosis Factor Agents in Rheumatoid Arthritis (STARA) Clinical Trial.

Take-home points from the discussion on the details about tapering biologics in rheumatoid arthritis, and a few final observations about the clinical trial under discussion at #rheumjc, the Twitter-based rheumatology journal club. That citation again: van Herwaarden N, van der Maas A, Minten MJ, et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ. 2015;350:h1389. doi: 10.1136/bmj.h1389.

A few concluding observations. Are rheumatologists following in the footsteps of oncologists?