℞ Strategy: Taper & Flare


In their discussion of RA flares and tapering treatment, Drs. Cush and Kavanaugh cover the BeST, AVERT, RETRO, and DRESS studies

Comparing a tapering strategy to the standard dosing regimen of TNF inhibitors in rheumatoid arthritis patients with low disease activity

Full Papers; Authors: Chamaida Plasencia, Gertjan…

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

Review; Authors: Mei Jiang, Feifeng Ren, Yaning Zheng, Ruyu Yan, Wenhan Huang, Ning Xia, Lei Luo, Jun Zhou, Lin Tang
Rheumatol Ther. 2017 Mar 2. doi:…


Stopping Biologic in RA Doesn’t Trigger Disease Flare

Almost 80% remained in low disease activity for 3 years

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

This study was conducted to evaluate the feasibility of long-term adalimumab (ADA) discontinuation after achievement of low disease activity (LDA) in Japanese patients with early rheumatoid arthritis (RA) and to identify predictors of LDA maintenance. In the HOPEFUL-1 study, patients received initia…

“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

Approximately 1 in 3 patients with rheumatoid arthritis (RA) who discontinued tofacitinib maintained low disease activity after 1 year. Low baseline rheuma

Tapering conventional synthetic DMARDs in patients with early arthritis in sustained remission: 2-year follow-up of the tREACH trial

Objectives With early and intensive treatment many patients with early RA attain remission. Aims were to investigate (1) the frequency and time to sustained remission and subsequent tapering in patients initially treated with conventional synthetic disease modifying anti-rheumatic drug ((cs)DMARD) s…

Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions

Improvements in the control of inflammation in rheumatoid arthritis (RA) by conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs) have led to a substantial change in the clinical outcomes of patients during the last 30 years. Current treatment can lead to sustained remis…

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.