Discontinuing biologics in axial spondyloarthritis 'not a good idea'
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DESTIN, Fla. — New data on discontinuation or dose reduction of biologic therapies has led to a shifting landscape in axial spondyloarthritis management, according to a speaker at the Congress of Clinical Rheumatology East annual meeting.
“We want to control disease activity,” Nigil Haroon, MD, PhD, head of the division of rheumatology at the University Health Network and Sinai Health, in Toronto, and past president of the Canadian Rheumatology Association, said in his presentation. “We also want to slow disease progression.”
The good news is that both of these treatment outcomes are increasingly possible now that there are four biologic mechanisms of action available in axial SpA, including TNF inhibition, interleukin (IL)-17a or IL-17a/f inhibition, along with Janus kinase (JAK) inhibition.
“You can really take four paths for the treatment of axial SpA,” Haroon said.
Meanwhile — in further good news — patients are being identified and diagnosed earlier.
“There has been a lot of emphasis on early identification of patients in past few years,” Haroon said. “Early initiation lowers risk for spinal fusion and cardiovascular outcomes.”
Early treatment may also lead to “deeper remission” for patients, he added. However, the larger question in the specialty at the moment pertains to when treatment may be reduced or discontinued once this deep remission has been achieved, according to Haroon.
“Biologic discontinuation is something we should talk about because more and more patients are doing well in the clinic,” he said.
According to Haroon, there are significant challenges regarding the efficacy and adherence for long-term treatment of axial SpA. However, there are significant risks involved in taking patients off treatment, such as making it difficult to “recapture” remission, he said.
“We are losing quite a number of patients to flare,” Haroon said. “In some studies, patients can be recaptured, but I am not confident in discontinuing treatment all of a sudden.”
The data on discontinuation are clear. Findings from the ABILITY-3 trial showed that, compared with continuing treatment with the TNF inhibitor adalimumab (Humira, Abbvie), discontinuation after sustained remission at 28 weeks led to “significantly more” flares. “We know that discontinuation is not a great idea,” Haroon said.
Similar findings were reported for IL-17 inhibition in the COAST-Y study.
“Whether it is radiographic or non-radiographic [axial SpA], we are seeing similar results,” Haroon said.
This brings the discussion to dose reduction.
Findings from the C-OPTIMIZE study included patients who reached remission after 48 weeks of treatment with the TNF inhibitor certolizumab pegol (Cimzia, UCB). Patients could continue treatment, receive a half dose or stop altogether.
“As expected, stopping is not a good idea,” Haroon said. “Almost 80% had flare of disease.”
However, patients in the half-dose group experienced comparable results with those who continued with the full dose.
“This may be the first place to start if you are looking to decrease biologic treatment in your patients,” Haroon said.
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Haroon N. Developments in Axial Spondyloarthritis. Presented at The Congress of Clinical Rheumatology East; May 9-12, 2024; Destin, Florida (hybrid meeting).
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