You Can Safely Reduce Medications in RA .... Sometimes

Dr. Sterling West highlighted recent evidence discussing tapering or reducing biologics in RA patients with low disease activity (LDA) or remission during this year’s Clinical Year in Review. In the past year there have been 6 trials that have looked at tapering anti-TNF therapy in early rheumatoid arthritis (ERA). Patients with ERA who achieve an early, sustained, and deep remission are most likely to maintain it with reduction of therapy (Emery NEJM 2014). The group that maintained remission the best were the ones who achieved remission quickly, had a deep remission (Boolean remission), and had no minor flares after achieving remission.

What about established RA? A group of patients with established RA were treated with adalimumab or etanercept for 6 months. Those achieving LDA according to DAS were randomized to dose reduction vs usual care. About 12% in the dose reduced group had a major flare vs 10% in the usual care group. However, 73% in the dose reduction group had small flares vs 27% in the usual care. In the dose reduction group, anti-TNF therapy could be discontinued in 20% and the injection interval could be increased in 43%. Again, the patients that maintained remission with a reduction in therapy were those who achieved deep Boolean remission and those who achieved prolonged sustained remission.

Summary

A reduction in therapy is best in patients who are in deep sustained remission with no minor flares
Tapering therapy is more successful than complete withdrawal
Stopping traditional DMARDs is not advised
Over 80-90% who flare are able to recapture response

More reports from ACR 2015