Review: A Pragmatic Approach to Tapering Biologics in RA
A new clinical review, published in the journal Clinical Rheumatology, discusses different tapering strategies for patients with rheumatoid arthritis (RA) using various biologic disease-modifying anti-rheumatic drugs (bDMARDs).
The optimal RA therapy in daily clinical practice is based on the treat to target (T2T) strategy which focuses on "successive escalation of immunosuppression... to achieve remission (REM) or low disease activity (LDA)." However, whether initial immunosuppression with bDMARDs can be de-escalated while maintaining treatment goals is still unclear.
A reason for considering de-escalating is that over time, "the risks of immunosuppression with bDMARDs may outweigh the benefits of continuing therapy." However, the risk of the disease flare is present, and the inability to to attain disease control with the same bDMARD therapy can be concerning for clinicians.
For patients with early RA who discontinued treatment, 40–90% of patients on anti-TNF treatment had no flare at one year compared to 25% for abatacept. For patients with established RA who discontinued treatment, 10–60% of patients on anti-TNF treatment had no flare at one year compared to 40–60% for abatacept and 10–13% for tocilizumab.
With regards to tapering, for patients with early RA who had their dose tapered, 80–90% of patient on anti-TNF treatment had no flare at one year versus 36–66% of patients on abatacept. For patients with established RA that had dose tapering, 25–90% of patients on anti-TNF treatment had no flare at one year.
The authors of this new review examined treatment de-escalation of various anti-tumor necrosis factor (TNF) and non-TNF therapies from the most recent observational, pragmatic, and controlled clinical trials. Based on their analysis, the researchers identified six key clinical pieces of information that may help clinicians in selecting the optimal patient for successful de-escalation of bDMARD:
1. Disease duration: early RA preferred over established RA
2. Initial DMARD used: upfront induction anti-TNF with methotrexate (MTX) favored
3. Current bDMARD treatment: evidence-based data available for anti-TNFs, abatacept, tocilizumab
4. Concomitant non-biologic DMARD (nbDMARD): continuing backbone therapy with nbDMARD preferred
5. Disease control (depth and length): 6–12 months of sustained remission preferred
6. Musculoskeletal ultrasound assessment: absence of grayscale and power Doppler synovitis preferred
Once the patient is selected for tapering, the process starts by increasing the interval between injections (guided by disease activity), while maintaining the same dose per injection. Reducing the dose, rather than stopping treatment all together, is recommended as discontinuation is associated with significantly higher rates of flare.
The authors of the review call this method of de-escalation a ‘pragmatic approach' to biological tapering. The patient should be monitored carefully for 3 to 6 months following the dose reduction to ensure that disease control is maintained. In a scenario were disease control is lost, "a reincrease of the same bDMARD to the prior effective dosing interval should be pursued, since recapture of disease control is achieved in over 90% of patients by 3 to 6 months." Further tapering while on the same bDMARD should not be attempted.
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