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Kavanaugh Reviews Treatment Discontinuation Data for RA
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CLEVELAND — In a presentation at the Biologic Therapies VII Summit, Arthur Kavanaugh, MD, reviewed the latest data for treatment de-escalation and discontinuation for patients with rheumatoid arthritis.
“We have grown up with the bias that tapering treatment is not a good idea and it is not going to work,” Kavanaugh, a professor of medicine at the University of California, San Diego, said. “But, things have happened since then. We have different treatment modalities. We are treating more aggressively and we are treating to target, and so now, this is an idea we are beginning to think about.”
Kavanaugh mentioned the CORRONA trial, which showed patients with rheumatoid arthritis (RA) who had low disease activity (LDA) may have a prolonged benefit after stopping tumor necrosis factor inhibitors (TNFi). Of the 35,656 patients in the study, 717 discontinued their first TNFi while in a LDA. At 6 months, 98.7% of patients showed benefit. This figure dropped to 73.4% after 12 months, to 55.6% after 18 months, to 42.2% after 24 months and to 27.6% after 36 months.
He noted that research from the BeST trial demonstrated RA flares were associated with greater functional impairment. In addition, Kavanaugh said researchers from the DRESS study showed how a stepwise increase in dosage interval could be performed clinically every 3 months; however, no co-treatment variables were associated with dose reduction or discontinuation of TNFi. A fourth study, the STRASS trial, showed sustained tapering of TNFi or discontinuation could be achieved in 43% of patients during a span of 3 years when there was limited dose reduction. He noted there was no difference between serum concentrations of adalimumab or etanercept at time of initiation that could predict relapse in patients with RA and LDA.
Kavanaugh also cited data presented at ACR in 2013 which demonstrated low-dose etanercept was non-inferior to the standard dose in terms of clinical scores; however, it was inferior in terms of synovitis on ultrasound. He noted that in Denmark a new guideline mandated patients with RA in sustained remission who were on biologics must attempt dose reduction by a “predefined algorithm.” After 1 year, the program showed 70% of patients who tapered had flares; however, these patients were re-escalated and regained remission.
“We do not know which patients,” Kavanaugh said. “Some patients can taper. Some patients can stop. We need to watch them. We need to treat if they flare at all, but we do not know how to identify other than doing it.” – by Will Offit
Reference:
Kavanaugh A. “Predicting the outcome of treatment de-escalation or discontinuation: What do we know?” Presented at: Biologic Therapies VII Summit; April 4-8, 2017; Cleveland.
Disclosure: Kavanaugh reports he has consulted and was an independent contractor, which includes contracted research, for Pfizer and was an independent contractor for Abbott, Amgen, Bristol-Myers Squibb, Centocor and UCB.