Abstract
The effectiveness of biologic therapies now means that remission or low disease activity are realistic targets for treatment. However, after achieving remission/low disease activity, the next steps remain unclear. The aim of this publication was to conduct a broad systematic literature review to evaluate dosing down of biologics. After screening papers and abstracts for relevance and application of inclusion/exclusion criteria, a structured extraction process was used to collect information on the included studies. Fifty-two papers were included in the analysis across rheumatic disease. In patients who discontinue therapy, remission is not typically sustained, with reported rates of relapse and flare across early RA (48–54%), established RA (2–84%), axial spondyloarthritis (11–53%) and PsA (44.9%). In many cases, an acceptable disease activity can be regained upon retreatment. More research is needed to understand the long-term impacts of these strategies on efficacy, safety and cost.
Highlights
Biologic treatment for RA, PsA and axial spondyloarthritis is commonplace
A Cochrane review of down-titration and discontinuation strategies of TNF blockers in RA that included seven clinical trials of etanercept and adalimumab concluded that dose reduction of etanercept 50 mg weekly to 25 mg weekly, after at least 312 months of low disease activity (LDA), seemed as effective as continuing the standard dose, and discontinuation was inferior to continuation of treatment [11]
To be included in the final analysis, articles had to report primary data from studies conducted in adults with RA, PsA or axial SpA; be related to a therapy listed as a primary search term in Table 1; and the issue of biologic tapering had to be mentioned in the title or abstract
Summary
Biologic treatment for RA, PsA and axial spondyloarthritis (axial SpA) is commonplace. Despite intense debate over definitions, remission rates in RA have doubled in the decade 200010 [6] It is unclear whether the dose should be maintained, titrated down or withdrawn. A Cochrane review of down-titration and discontinuation strategies of TNF blockers in RA that included seven clinical trials of etanercept and adalimumab concluded that dose reduction of etanercept 50 mg weekly to 25 mg weekly, after at least 312 months of LDA, seemed as effective as continuing the standard dose, and discontinuation was inferior to continuation of treatment [11]. We attempted to answer seven core questions through auditing and analysing the literature, as well as to create a research agenda for future projects and studies
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