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RheumThoughts: Should You De-escalate DMARDs in RA?


Hello, I'm Richard Conway from Dublin, Ireland and I'm here to talk to you about RheumNow's campaign in rheumatoid arthritis entitled Hard Decisions in RA. I'm here to talk about de-escalation of DMARDs in patients who are in remission, so dose reduction, stopping drugs in patients who are doing well.

So you've got this patient sitting in front of you, seropositive rheumatoid arthritis, and you've worked hard and you've increased their drugs. You've got them into remission. They're now on methrotrexate and adalimumab combination therapy and they come in, and they say,"Doc I'm doing great thanks a million." And you turn around and you say to them, "you know what - I think we're going to give you less of these drugs that are working well." And they say, "no don't do that, why would you want to change something when somebody's doing so well?" 

There's a lot to be said for if it ain't broke, don't try and fix it.

We do really well when patients come to see us first, and we have this treat the target algorithm, and we really buy into this. We try really, really hard to get patients into remission. We aggressively increase drugs to do that, and then it seems once we have a patient in remission, we're not happy to just say: okay I'm going to do nothing to you, I'm going to leave things be.

For some reason, we feel the need that we either need to be increasing drugs or decreasing drugs. We need to do something at each Clinic visit, and I think that is a psychological thing we need to try and overcome.

And it seems then, that, okay, we accept that we shouldn't allow patients to have any symptoms really, or any flareups when we're trying to achieve remission. But we take away the drugs or we allow them have a little so make some pains maybe a flare or two that's okay it doesn't really matter. But it does.

There are multiple studies now which have shown that if you try and dose reduce, and especially if you try and stop one of the drugs the patient is on, that the flare rates are high. They may not flare immediately; first year maybe 50% of people will flare if you stop their drugs. But ultimately most people seem to flare and that's not something we should necessarily accept. The flare itself that happens, it may cause irreversible joint damage. There are other consequences outside of the joints, so the increasing disease activity is potential negative consequences for cardiovascular outcomes, for rheumatoid interstitial lung disease. It's also reported in many of these studies as a kind of positive thing: oh if the patient flares and you restart a drug they were on 85 to 90% of them will regain remission or low disease activity. But that means that 10 or 15% of these patients who are previously in remission will not recapture that - they will be harder to get back under control and suffer more because of this.

The ACR and Eular guidelines broadly support this approach, the ACR more strongly than the Eular guidelines where they essentially say, do not do this. They recommend continuing drugs, not reducing doses, not stopping drugs. If you are going to do something it seems to be slightly worse or slightly less risky to dose reduce and to stop a drug and less risky to stop something like methotrexate than it is to stop a biologic. But these are probably questions that the vast majority of time we shouldn't really be thinking about. We shouldn't be even considering doing this.

There's one exception to this, there's one scenario where we have to consider this and that's as part of shared decision making where a patient comes to you and says I really want to reduce this drug for whatever reason. That's something we need to take on board. We need to be open to that discussion. But a key part of shared decision-making is passing on the knowledge that we have that this is a gamble, this is a risky thing to do, and actually most of the time it will not end end up terribly well. Best case scenario, you'll end back up on the drugs you try to stop and worst case scenario, you can suffer quite a bit along the way to regain that.

Bottom line here I'm saying: de-escalation of drugs in rheumatoid arthritis - do not do it. If you think about it, think about it again, think about it again, and be really sure before you try and do it.

Thank you for listening to me. I'm Richard Conway and please check out RheumNow for all the updates in this campaign on rheumatoid arthritis.

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Tarun Sharma

| Sep 14, 2023 5:11 pm

‪Nice commentary! Our tendency to think binary can sometimes be problematic- I always urge fellows to embrace the paradoxes. Agree tapering is not for everyone, stopping is definitely not. Like you mentioned tapering could be considered for that interested patient, perhaps seronegative in deep remission w PtGA 0.‬ Keeping an open mind only facilitates shared decisions informed by the evidence. Could slowly tapering MTX to 1/2 dose be an option for the above pt (Arctic rewind study JAMA 2021 but w slow taper not abrupt, and Meta-analysis on MTX de-esc Meng et al 2023)‬ ?

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Richard Conway is currently a consultant rheumatologist and physician at St. James’s Hospital and a clinical associate professor at Trinity College Dublin. He has a PhD in Giant Cell Arteritis. He is the author of more than 150 peer-reviewed publications and 3 book chapters. His research interests include interstitial lung disease in systemic rheumatic diseases, vasculitis, and polymyalgia rheumatica. Follow him on Twitter at @RichardPAConway.