BeST, AVERT, RETRO, and DRESS
Comparing a tapering strategy to the standard dosing regimen of TNF inhibitors in rheumatoid arthritis patients with low disease activity
Efficacy and safety of down-titration versus continuation strategies of biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis with low disease activity or in remission: a systematic review and meta-analysis
Stopping Biologic in RA Doesn’t Trigger Disease Flare
Low disease activity for up to 3 years after adalimumab discontinuation in patients with early rheumatoid arthritis: 2-year results of the HOPEFUL-3 Study
“The results of this 104-week follow-up study indicated that approximately 80% of the Japanese patients with early RA were in LDA after 3 years ADA discontinuation. However, it must be noted that there was a significant difference in the proportion of patients who achieved LDA among patients who discontinued ADA compared with patients who continued to receive ADA. The initial therapy had no effect on LDA sustainability in either the ADA continuation group or the ADA discontinuation group. However, initial intensive therapy with ADA + MTX was associated with a better outcome in terms of suppression of joint destruction compared with standard therapy.”
Low Disease Activity After Tofacitinib Discontinuation in Rheumatoid Arthritis
Tapering conventional synthetic DMARDs in patients with early arthritis in sustained remission: 2-year follow-up of the tREACH trial
Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions
The hope of achieving a cure has indirectly spawned the idea of a “window of opportunity”, in which early aggressive treatment can improve the chances of sustained remission or even drug-free remission eventually.
In RA, clinical trials and extension studies data suggest this window to be 3-6 months from the onset of unremitting joint pain, and the likelihood of successful drug tapering and drug-free remission to be in the order of 14-21%. The caveat is that the frontloading treatment is with the costly targeted therapies, used for at least 6 months.
The data also suggest that tapering should not be attempted if only low disease activity is achievable, rather than deep remission, because RA flares are more likely.
Should flares happen, re-induction with the same agents which delivered the initial remission is usually successful.