title: De-intensifying treatment in established rheumatoid arthritis (RA): Why, how, when and in whom can DMARDs be tapered?
abstract: As more patients with established rheumatoid arthritis (RA) achieve remission or low disease activity, strategies such as tapering and withdrawal of disease-modifying antirheumatic drugs (DMARDs) are being investigated. In several trials, DMARD discontinuation was associated with a higher risk of relapse, ranging from 56% to 87% at 1 year. Tapering, either by dose reduction or by injection spacing, may limit the risk of relapse. Half-dose etanercept (ETN) versus full-dose continuation was not associated with an increased relapse risk at 1 year in two trials. Progressive antitumor necrosis factor injection spacing was shown to be equivalent to full regimen continuation in terms of persistent flare and disease activity at 18 months in one trial, but not in another one. Reintroduction of a DMARD at previous dose/regimen was usually associated with remission re-induction. The risk of relevant structural damage progression was not increased. Safety improvement has not yet been demonstrated. The annual cost reduction when tapering biologic DMARDs (bDMARDs) was 3500-6000 €/patient. Research questions to be addressed include defining flare that requires reinitiation of treatment, such that patients facilitate the maintenance of remission during tapering by timely communication with their rheumatology team.
authors.affiliation: Pierre et Marie Curie University - Paris 6, Sorbonne Universités, GRC-08 (EEMOIS), Paris, France; APHP, Rheumatology Department, Pitié Salpêtrière Hospital, F-75013, Paris, France. Electronic address: bruno.fautrel@psl.aphp.fr.
authors.forename: Bruno
authors.initials: B
authors.lastname: Fautrel
authors.affiliation: Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.
authors.forename: Alfons A
authors.initials: AA
authors.lastname: Den Broeder
mesh_terms: D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy*; D001685:Biological Factors / Q000627:therapeutic use; D000068800:Etanercept / Q000627:therapeutic use; D006801:Humans; D012008:Recurrence; D012074:Remission Induction
chemical_list: D018501:Antirheumatic Agents; D001685:Biological Factors; D000068800:Etanercept
keywords: De-escalation; Dose reduction; Remission; Rheumatoid arthritis; Spacing; Step-down strategy; Treatment discontinuation; Treatment tapering; bDMARD; csDMARD