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The Great Debate: But Not a Recap of Hillary vs. Donald!
Marlene Thompson
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November 15 2016 1:00 PM ET — via RheumReports 
For anyone who was expecting a heated debate similar to the United States presidential debates, today's debate on "To Taper or Not to Taper? Biologic DMARDs in Low Rheumatoid Arthritis Disease Activity" was not the place to be. Dr. Arthur Kavanaugh, who argued for not tapering at all, ended up agreeing with Dr. Paul Emery, who presented the case for tapering.
Dr. Emery focused on tapering for patients who receive early treatment. He showed data from the AGREE, PRIZE, C-Early and PRESERVE studies, all which showed that patients who receive early treatment and achieve remission of symptoms within 6 months should be able to reduce the dose of TNF inhibitors without flaring.
The OPTIMA trial showed that early RA patients responding to 26 weeks of ADA and MTX can achieve good outcomes with MTX monotherapy over an additional 52 weeks. The principal factor associated with biologic-free disease control and absence of flare was better function (lower HAQ) at baseline.
Dr. Emery also pointed out that radiographic progression was essentially switched off in patients who achieved remission and that achieving remission was protective against radiographic progression after stopping the TNFi medication. Overall, 1 in 10 patients will flare after stopping TNFi medications. However, response can be recaptured in 75% of those patients. He argued that it does not make sense to spend increased money and expose patients to increased risk of adverse events when the percentage of patients that cannot be recaptured is so low. He did note that those patients whose disease has progressed will have difficulty stopping because they have stopped before and flared, or use of their damaged joints will cause them to flare. The take home message is that in late disease, not all patients are the same.
He also argued that patients who are CCP-negative have less immunological drive and are thus more likely to sustain remission on reduced doses. In patients who are anti-CCP positive, response to TNF dose reduction will generally correlate with how they responded to methotrexate.
Dr. Kavanaugh tried to build his case against tapering medications by stating that immunopathogenesis is always present. That is, once the immune process has been triggered, there will always be an underlying immune-driven systemic inflammatory process. Although patients may be clinically stable, discontinuing TNFs for even a short period of time will allow the underlying disease to come back.
Dr. Kavanaugh also addressed the economics of disability and problems associated with flaring. Finally, he discussed the adverse events that can result with treatment discontinuation. Despite these arguments, he still seemed to agree with Dr. Emery that tapering, when feasible, is best.
The issue of dose reduction or discontinuation in patients with low disease activity but who are not currently in clinical remission remains unresolved.
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About the Author
Marlene Thompson
Marlene Thompson is an Associate Clinical Professor in Physical Therapy at Western University and an Advanced Physiotherapy Practitioner in Arthritis Care. MarleneÔǦs research interests include models of care, triage, advanced practice roles, and arthritis education.
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