title: Tapering biologics in rheumatoid arthritis: a pragmatic approach for clinical practice.
abstract: Optimal rheumatoid arthritis (RA) therapy in daily clinical practice is based on the treat-to-target strategy. Quicker escalation of therapy and earlier introduction of biological disease-modifying anti-rheumatic drugs have led to improved outcomes in RA. However, chronic immunosuppressive therapy is associated with adverse events and higher costs. In addition, our patients frequently express a desire for lower dosing and drug holidays. Current clinical practice guidelines from the American College of Rheumatology and European League Against Rheumatism suggest that rheumatologists consider tapering treatment after achieving remission. However, the optimal approach for tapering therapy in RA, specifically de-escalation of biologics, remains unknown. This clinical review discusses biologic tapering strategies in RA. We draw our recommendations for everyday clinical practice from the most recent observational, pragmatic, and controlled clinical trials on de-escalation of biologics in RA. For each biologic, we highlight clinically relevant outcomes, such as flare rates, recapture of the disease control with retreatment, radiographic progression, side effects, and functional impact. We discuss the use of musculoskeletal ultrasound to select patients for successful tapering. In conclusion, we provide the reader with a practical guide for tapering biologics in the rheumatology clinic.
authors.affiliation: Division of Rheumatology, Department of Internal Medicine, University of Kentucky, Kentucky Clinic J507, 740 South Limestone St, Lexington, KY, 40536, USA. aleks.lenert@uky.edu.
authors.forename: Aleksander
authors.initials: A
authors.lastname: Lenert
authors.affiliation: Division of Immunology, Department of Internal Medicine, The University of Iowa, C428-2GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
authors.forename: Petar
authors.initials: P
authors.lastname: Lenert
mesh_terms: D000069594:Abatacept / Q000008:administration & dosage; D000068879:Adalimumab / Q000008:administration & dosage; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage; D018501:Antirheumatic Agents / Q000008:administration & dosage; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000008:administration & dosage*; D000068582:Certolizumab Pegol / Q000008:administration & dosage; D004334:Drug Administration Schedule; D000068800:Etanercept / Q000008:administration & dosage; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D000069285:Infliximab / Q000008:administration & dosage; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging; D012219:Rheumatology / Q000379:methods*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D014463:Ultrasonography
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D001688:Biological Products; D007166:Immunosuppressive Agents; C439524:TNF protein, human; D014409:Tumor Necrosis Factor-alpha; D000069594:Abatacept; D000069285:Infliximab; D000068879:Adalimumab; C502936:tocilizumab; D000068800:Etanercept; D000068582:Certolizumab Pegol
keywords: Biologic therapy; Discontinuation; Musculoskeletal ultrasound; Rheumatoid arthritis; Tapering; Treat to target