In patients with rheumatoid arthritis (RA) who are receiving biological disease-modifying antirheumatic drugs (bDMARDs) and in remission, relapse is less likely when bDMARDs are tapered rather than discontinued, a systematic review and meta-analysis published in the Annals of the Rheumatic Diseases.
Current RA guidelines recommend decreasing or stopping bDMARDs once a patient has achieved stable remission or low disease activity (LDA), but the question of how to do this safely is still under discussion.
Sophie Henauz, and colleagues from Hôpital Purpan in Toulouse, France, approached this problem using a systematic literature analysis plus meta-analysis to compare outcomes for discontinuing or tapering bDMARDs and continuing bDMARDs in patients with RA in remission or at LDA status.
The study authors conclude that risk of losing remission or risk for relapse from a state of LDA was lower in patients whose bDMARD doses were tapered than in those whose bDMARDs were discontinued.
"I don't think many would disagree with the conclusion that tapering treatment is likely better than stopping it completely, in terms of disease activity. The crucial point for clinicians is that these are group-level data," said Arthur F. Kavanaugh, professor of Clinical Medicine Director, Center for Innovative Therapy at the University of California.
"There are patients who stop treatment and remain in remission for years and have no X-ray progression, and there are patients who taper who flare and have X-ray progression. So this doesn't really provide strong guidance for what to do with individual patients." Dr Kavanaugh added.
The authors carried a systematic analysis of prospective controlled trials that included reducing or discontinuing bDMARDs (except for rituximab) in patients with RA that was in stable remission (disease activity score on 28 joints [DAS28]-erythrocyte sedimentation rate [ESR] <2.6) or in a state of LDA (DAS28-ESR <3.2).
The literature review identified 13 published articles and four abstracts for analysis. This included 1054 patients who continued bDMARDs and 766 who discontinued bDMARDs. The monitoring period was 1 year. Among the studies of bDMARD tapering, 755 patients continued bDMARDs and 835 patients reduced bDMARD doses.
Discontinuing bDMARDs roughly doubled the risk of losing remission or LDA status compared with continuing bDMARDs (risk ratio [RR], 1.97 [P < .0001] and 2.24 [P < .0001], respectively). Discontinuing bDMARDs was also associated with an increased risk for radiographic progression (RR, 1.09; P = .01).
Tapering bDMARDs appeared somewhat less risky. The meta-analysis comparing bDMARD tapering with bDMARD continuation showed an increased risk of losing remission (RR, 1.23; P = .006), but no increased risk of relapsing from LDA (RR, 1.02; P = .81) and for radiographic progression (RR, 1.09; P = .26).
The authors conclude, "Our meta-analysis reveals that, in RA patients with remission or LDA, discontinuation of bDMARDs leads to an increased risk of losing remission or LDA and radiographic progression, while tapering doses of bDMARDs does not increase the risk of relapse (LDA) or radiographic progression, even though there is an increased risk of losing remission, in comparison with continuation of the initial bDMARD regimen."