Tapering biological DMARDs in patients with low RA disease activity achievable in daily practice
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Dose reduction of biological DMARDs in patients with rheumatoid arthritis who have achieved low disease activity is a feasible goal in daily practice, according to data published in Arthritis Research & Therapy.
“A significant proportion of RA patients achieve low disease activity or remission when treated with a biological DMARD,” Patrick Durez, MD, of the Catholic University of Louvain, in Brussels, Belgium, told Healio Rheumatology. “We know from several studies that tapering biological DMARDs is feasible and does not compromise the long-term benefit of such therapies.”
To assess the proportion and characteristics of patients who can taper biological DMARDs in daily practice, Dierckx and colleagues studied data from 332 patients with RA from the Catholic University of Louvain. Among these patients, 140 received a tapered regimen of biological DMARDs while 192 were treated with stable doses.
The researchers assessed each patient and recorded the age at diagnosis, age at the start of the current biological drug, age at the time of the study, sex, smoking status, presence of rheumatoid factor or citrullinated antipeptide antibodies, presence or absence of radiological erosion, duration of the disease at the introduction of the first conventional synthetic DMARD and biological DMARD, and the number of biological DMARDs received.
Patient global assessment (PGA) score, Health Assessment Questionnaire (HAQ) score, CRP level, number of tender and swollen joints, Disease Activity Score-28 for Rheumatoid Arthritis with CRP (DAS28-CRP) and concomitant use of methotrexate and/or glucocorticoids were also noted.
Data showed that age at diagnosis (43.1 years vs. 38.7 years; P=.04), health assessment questionnaire (HAQ) score (1.3 vs. 1.5; P=.048), rheumatoid-factor positivity rate (83.3% vs. 72.9%; P=.04) and disease duration at the time of bDMARD introduction (9.7 years vs. 12.1years; P=.034) were significantly different between the tapered and stable groups. Further, more patients in the tapered group received a combined regimen of biological DMARDs and methotrexate, with 86.7% compared with 73.8% in the stable-dose group (P=.005).
“Our study is one of the first to evaluate biological DMARD dose reductions in standard daily care and to analyze which patient characteristics could be correlated with such strategies,” Durez said.
Anti-TNF agents were the most prescribed medications, at 68%. Fifteen patients experienced a flare during follow-up. Adalimumab (Humira, AbbVie), etanercept (Enbrel, Amgen) and rituximab (Rituxan, Genentech) were the most common biologic DMARDs in the tapered group. These medications were associated with the most important reductions in annual cost.
“Tapering biological DMARDs in daily clinical care is an important strategy to individualize treatment while potentially minimizing unnecessary drug exposure and decreasing the toxicity and overall cost of treatment,” Durez said. “This approach could be tested for several bDMARDs, and our study indicates that the combination of biological DMARDs with methotrexate could improve the success of dose reduction attempts.” – by Jason Laday
Disclosures: The researchers report no relevant financial disclosures.
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David A. McLain, MD, FACP, FACR
In rheumatology practice, we have patients doing very well on biologic DMARDs for an extended period of time and we wonder if they really need the medication at this frequency or dose. Sometimes our patients taper the dose themselves by spacing out their doses.
The present study is relatively small and retrospective, analyzing two cohorts of RA patients: A reduced-dose group (RDG) that was permitted to taper bDMARDs by as much as over 50% and a stable-dose group (SDG) that was not. The RDG was older, older at diagnosis, had the presence of rheumatoid factor and had a shorter disease duration; only 11% of the RDG group flared on their reduced dose.
The majority of both groups were on concomitant methotrexate, but 13% more in the RDG, which was highly significant. There was no difference in steroid intake but the RDG had less RA activity as judged by a lower HAQ and PGA scores at entry; however, DAS-28 scores were similar. Over the course of the study, the RDG group also had tried fewer bDMARDs than SDG. Keeping patients on methotrexate turned out to be a good strategy as it resulted in a lower bDMARD dose and cost savings.
There are patients that we see in practice that do very well with a bDMARD right from the start, like hitting a home run. These appear to be the patients that are in the RDG. We follow them, often for years, and they continue to do very well. When do we decide to taper their bDMARD dose? I think we fear that tapering will cause a flare that will not respond to reinstituting the prior dose that was efficacious. We certainly have seen this scenario and I can remember some startling examples prior to the advent of bDMARDs. This article adds to our understanding of who might be an RA patient to consider bDMARD tapering — the early diagnosed, older patient who has had an excellent response to the chosen bDMARD.
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