Biologic discontinuation strategies and outcomes in patients with rheumatoid arthritis

ABSTRACT

Introduction: Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease, which affects joints as well as extra-articular tissues. In the last decades, increasing targeted therapeutic options dramatically improved RA management by doubling the rate of patients achieving clinical remission. Currently, there is a need for management strategies aimed at limiting treatment-related adverse events and costs in good responders.

Areas covered: Data on de-escalation of biologic drugs (especially for anti-TNF agents) are mainly available from post-hoc analyses of randomized controlled trials and from registry-based observational studies. This narrative review illustrates the rationales for dose tapering and expands to provide an overview of the efficacy of the different available strategies for reducing the exposure to biologic drugs in patients achieving a sustained clinical response. Selected studies are discussed as illustrative examples.

Expert opinion: Withdrawal of biologic therapy might be attempted in limited patients with very early RA; conversely, established RA is more suitably managed with a progressive decrease of drug regimen, by either dose reduction or injection/infusion spacing. Further studies investigating potential factors predicting post-tapering disease relapse are warranted, in order to better identify the best candidates for a decreased-dose approach.

KEYWORDS:

• Anti-TNF
• biologic agents
• costs
• dose
• efficacy
• rheumatoid arthritis
• safety
• spacing
• tapering

Article highlights

• Following the increase in the rate of RA patients achieving a sustained clinical response over the last decades, a new need emerged for defining strategies aimed at limiting potential adverse events and costs related to unnecessary, prolonged exposure to biologic drugs.

• A complete discontinuation of biologic agents might be a reasonable approach only for patients with very early RA, who received similarly early treatment.

• Progressive, disease activity-guided tapering of biologic therapy, by either dose reduction or injection/infusion spacing, might be the most suitable management strategy for patients with established RA achieving a sustained clinical response.

• Further studies are warranted in order to identify potential predictors of disease flare in patients tapering biologics.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.