November 10, 2016

Tapering DMARDs: Where are we now?

Raising more questions than answers

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By M. Elaine Husni, MD, MPH

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As the landscape of rheumatoid arthritis (RA) treatment matures, our ability to tailor treatment strategies to achieve clinical remission or low disease activity has grown to a level of patient expectation. Each week in clinic, several patients ask me about tapering their disease-modifying antirheumatic drugs (DMARDs). In fact, more recent studies suggest that a subset of RA patients who are treated aggressively at early stages may reach biologic-free remission or even drug-free remission.

Though we can’t yet call them cured, these patients do exist. We’re still working to determine if the disease simply has a different natural history in these patients, or if we have finally discovered the correct combination of early therapeutic intervention at the right “window of opportunity” to achieve remission.

The promise of drug-free remission, and its subsequent decrease in side effects of long-term medication use and in healthcare costs, is undoubtedly appealing, but many questions remain.

  • Can patients who taper and then flare be successfully rechallenged with DMARDs and assume their clinical remission state?
  • Can particular patient characteristics help guide who should be considering tapering or discontinuing DMARDs (i.e., anti-CCP positive, erosive changes or multiple associated RA comorbidities)?
  • What is the optimum length of treatment before tapering or discontinuing DMARDs?
  • Are RA-related comorbidities such as accelerated cardiovascular disease attenuated in these drug-free remission states?
  • When patients are on combination therapy, such as methotrexate and a biologic DMARD, which should you taper first?

Clues about when to taper

It’s difficult to answer the above questions for each individual patient, but there are tools to help us determine when a patient is ready to taper or discontinue DMARDs. For example, Doppler ultrasound can show clinical remission, immediately identify patients who may have subclinical inflammation after tapering or discontinuing biologics, and help assess efficacy of current treatment in patients with long-standing RA. Moreover, the combination of power Doppler ultrasound evaluation and ACR/EULAR remission criteria could help identify patients on biologics who are likely to achieve drug-free remission.

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As studies continue, shared decision-making key

Most rheumatologists agree that the decision to taper or discontinue RA treatment should be considered in patients who have remained in stable remission, and that the “deeper” the remission, the more likely the success of tapering or discontinuing DMARDs.

A true patient-provider shared decision-making process is critical as further studies are underway that may guide us in selecting the most favorable treatment strategies in the near future. Additional studies are necessary to best understand conditions that lead to the re-establishment of tolerance during remission and the molecular mechanisms of drug-free remission. At the upcoming Biologic Therapies VII Summit, Arthur F. Kavanaugh, MD, Director of the Center for Innovative Therapy at the University of California at San Diego School of Medicine, will address these issues of treatment de-escalation and discontinuation at length.

Biologics VII, to be held April 6-8, 2017, at the Intercontinental Hotel and Conference Center in Cleveland, Ohio, will highlight the challenges and opportunities of precision medicine and is designed for all clinicians caring for patients with autoimmune and/or autoinflammatory diseases. For registration and additional information on the Summit, visit www.ccfcme.org/biotherapiesVII.

This activity has been approved for AMA PRA Category 1 Credit™.

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Dr. Husni (husnie@ccf.org; 216.445.1853) directs both the Arthritis and Musculoskeletal Treatment Center and Cleveland Clinic’s Psoriatic Disease Biobank.

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