Friday, 06 Dec 2019

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Tapering Of Therapy In RA: Maybe Not So Aggressive Next Time

This ACR has seen some more great work on tapering of therapy in rheumatoid arthritis. It’s a hot topic and one which I get asked about all the time by my patients. Commonly when I start oral csDMARDs patients want to know how long they be will on therapy and that naturally leads to a discussion about what the plan will be in the future about tapering.

The data is late breaker abstract L08, presented by Siri Lillegraven from Oslo in Norway, and including researchers such as Dan Solomon from Brigham and Women’s and Desiree van der Heijde from Leiden. They completed a non-inferiority design study where 160 rheumatoid patients in clinical remission for at least 12 months on stable csDMARD therapy were randomly assigned to continued stable csDMARD or half dose csDMARD. The primary endpoint was the proportion of patients with a disease flare over 12 months (a combination of DAS > 1.6, a change in DAS > 0.6 and at least 2 swollen joints, or both the physician and patient agreed that a clinically significant flare had occurred). 79% and 84% of patients in the stable and half dose groups respectively were on MTX monotherapy, so this is largely a trial about the success of withdrawing therapy in those on MTX monotherapy. 6.4% of the stable group flared and 24.7% of the half dose group flared. The result was not non-inferior to stable dose csDMARDs. No progression of radiographs was seen in 80% versus 63%, stable and half-dose respectively. At 12 months 92% and 85% were in DAS remission, stable and half-dose respectively. 75 adverse events were seen in the stable group and 53 in the half-dose group.

So, what is the take-home from these data? I think a big take home is that csDMARDs can be tapered with no issues in around three quarters of patients. This leads to reductions in adverse events, and minimal loss of DAS remission. And importantly, for those who do flare, or lose their remission, you can, of course, put the dose back up. This is a great reminder that we can reduce doses of csDMARDS, adverse events and cost by being proactive with tapering csDMARD doses. But, I have to admit, I go a bit slower as treatment of rheumatoid is a life-long pursuit.

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