Tapering and termination of immunosuppressive treatment in spondyloarthritides (including psoriatic arthritis)

Abstract

Immunomodulatory long-term treatment has also become the standard treatment for spondyloarthritides (SpA), including psoriatic arthritis (PsA); however, uncertainty exists about dose reduction or termination of treatment after remission or low disease activity. When is it possible to reduce medication or terminate treatment for SpA? An extensive non-systematic literature search was performed focusing on practice guidelines, systematic meta-analyses and clinical trials on medicinal long-term treatment and voluntary medication reduction in axial and peripheral SpA, including PsA. The chances of drug-free remission after treatment with biologics for axial SpA and in PsA are low; however, in remission or astate of low disease activity reduction of the cumulative dosage of biologics can be successful in 53-100% of cases without a significant increase in disease activity. The current state and duration of remission, with or without comedication with nonsteroidal anti-inflammatory drugs (NSAID), extra-articular disease manifestations and the results of previous treatment attempts have to be carefully taken into consideration before elective dose reduction. Reduction of long-term treatment is an individualized decision made jointly by patients and physicians. The risk of flares and especially of extra-articular disease manifestations needs to be weighed against the possible advantages of reduced medication. Maintainenance of mediction-free disease remission is too rare in SpA or PsA patients carefully selected for biologics treatment, to allow alater voluntary termination of therapy, without at least aprior cautious attempt at dose reduction.