Abstract
Once remission or low disease activity (LDA) is reached in established rheumatoid arthritis (RA) patients, attempting disease-modifying anti-rheumatic drug (DMARD) tapering seems relevant to avoid patient overtreatment. Potential benefits include reduction in treatment burden and risk of adverse events, although the latter has not been convincingly shown. Feasibility of DMARD discontinuation has been tested in numerous studies or trials. All have shown high risk of relapse ranging from 56 % to 87 % at 1 year. Although remission/LDA can usually be re-established with re-initiation of previous treatment, such risk appears more harmful than beneficial. DMARD tapering, either by dose reduction or injection spacing, is conceptually more acceptable, and two superiority randomized controlled trials (RCTs) comparing half-dose étanercept to full dose continuation demonstrated no significant difference at 1 year. In contrast, two equivalence RCTs that tested disease activity-guided dose optimisation by progressive etanercept and adalimumab injection spacing versus continuation showed an increased risk of acute flare. Interestingly, one of them also demonstrated the equivalence of increasing injection spacing and standard of care in terms of recurrent flare and overall disease activity over the 18-month follow-up. The risk of structural damage progression was minimal or null. Reintroduction of DMARD at previous dose was associated with remission re-achievement in the majority of patients who flared. Tapering strategies respecting the Tight Control and Treat-to-Target principles seem relevant options for RA patients having achieved sustained remission or low disease activity.
Published Version
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