Dose tapering and discontinuation of biological therapy in rheumatoid arthritis patients in routine care –

 2-year outcomes and predictors

Background/Purpose: A cohort of routine care rheumatoid arthritis (RA) patients in sustained remission had biological disease-modifying anti-rheumatic drugs (bDMARDs) tapered according to a treatment guideline. We studied: 1) the proportion of patients whose bDMARD could be successfully tapered or discontinued; 2) unwanted consequences of tapering/discontinuation; 3) potential baseline predictors of successful tapering and discontinuation.
Methods: One-hundred-and-forty-three patients with sustained disease activity score (DAS28-CRP)≤2.6 and no radiographic progression the previous year were included. bDMARD was reduced to 2/3 of standard dose at baseline, ½ after 16 weeks, and discontinued after 32 weeks. Patients who flared (defined as either DAS28-CRP≥2.6 and DDAS28-CRP≥1.2 from baseline, or erosive progression on X-ray and/or MRI) stopped tapering and were escalated to the previous dose level.
Results: One-hundred-and-forty-one patients completed 2-year follow-up. At 2 years, 87 patients (62%) had successfully tapered bDMARDs, with 26(18%) receiving 2/3 of standard dose, 39(28%) ½ dose and 22(16%) having discontinued; and 54 patients (38%) were receiving full dose. DDAS28-CRP_0-2yrs was 0.1((−0.2)-0.4) (median(interquartile range)) and mean DTotal-Sharp-Score_0-2yrs was 0.01(1.15)(mean(SD)). Radiographic progression was observed in 9 patients (7%).  Successful tapering was independently predicted by: ≤1 previous bDMARD, male gender, low baseline MRI combined inflammation score or combined damage score (Figure). Negative IgM-rheumatoid factor predicted successful discontinuation. The “heat-map” for predicted probabilities for successful tapering based on logistic regression model including the 4 baseline variables are shown in Figure 2.

Conclusion: By implementing a clinical guideline, 62% of RA patients in sustained remission in routine care were successfully tapered, including 16% successfully discontinued at 2-years. Radiographic progression was rare. Maximum one bDMARDs, male gender, and low baseline MRI combined inflammation and combined damage scores were independent predictors for successful tapering.