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Tapering RA Therapy
Tapering Therapy in Rheumatoid Arthritis: My Approach

Released: July 14, 2016

Expiration: July 13, 2017

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With recent advancements in our ability to manage rheumatoid arthritis (RA), more patients are able to achieve sustained remission. For these patients, the possibility of tapering RA therapy has become a hot topic. Indeed, the American College of Rheumatology (ACR) guidelines address the process of tapering, carefully noting that it should be a conditional rather than mandated option, and should be driven by patient preferences and values.

My approach to tapering therapy is largely similar to the guidelines, particularly on a few key points. First, tapering of RA treatment should be considered only in patients who have achieved stable remission. This point is supported by data suggesting that the success of treatment tapering is linked to the depth of a patient’s remission. For example, patients with the lowest Disease Activity Scores (DAS) scores (eg, DAS28 < 2.6) have a more successful experience with tapering therapy. Patients who are in low disease activity should not undergo treatment tapering unless there is a tolerance or toxicity issue with their medication. The other key point where I am in agreement with the guidelines is that we should generally avoid withdrawing therapy. It is clear that with RA, we are treating but not curing the disease. Despite several studies exploring drug-free remission, the proportion of patients who successfully maintain remission following withdrawal of medication remains small (≤ 10%), indicating that withdrawal is not an appropriate goal for most RA patients. As an aside, ultrasound has shown some promise as a tool to help identify patients who are candidates for total withdrawal of therapy—namely, patients with no subclinical inflammation.

Sequencing of Tapering Agents
In my practice, most patients who reach the point of considering tapering therapy are receiving methotrexate plus a biologic agent. Thus, the question arises of which agent to taper first. I generally begin by tapering the dose of methotrexate, as this is typically the drug with the most adverse events (namely nausea). Moreover, this approach works well for most patients, who tend to view methotrexate as the less effective drug, because they began treatment with methotrexate alone and did not receive enough relief until adding the biologic. I am comfortable tapering the dose of methotrexate down to 10 mg per week where there is reasonable evidence that the synergy with the biologic agent remains in effect. I do my best to talk patients out of going below this dose, with one exception: patients who are receiving tofacitinib or tocilizumab. There is a convincing amount of evidence to suggest that methotrexate does not add benefit with these agents, so I am willing to gradually taper and consider withdrawing methotrexate in this setting.

Tapering Biologic Agents
The next decision is whether to taper the dose of the biologic agent. This is a more challenging question, as in many cases, adding the biologic helped achieve stable remission and neither my patients nor I want to jeopardize control of their disease. Ample evidence demonstrates broad benefit to patients who are in stable remission, including lower risks of cardiovascular disease, infections, and other complications. Whereas data from recent studies assessing tapering of etanercept and adalimumab have suggested that the biologic dose can be successfully tapered, those are relatively short-term results, and we do not yet know what the long-term implications will be of biologic tapering. For these reasons, I avoid tapering the biologic for most of my patients.

Tapering Therapy and Treat-to-Target
Finally, it is worth pointing out that beyond the cost and tolerability benefits, consideration of tapering therapy fulfills one of the key tenants of the treat-to-target approach: to practice shared decision making with our patients to determine treatment goals. In my practice, it is generally the patient who raises the issue of tapering therapy. Being able to respond to our patients’ needs serves the patient–provider relationship and may avoid adherence issues. Patients who feel that their provider is considering their wishes may be less likely to discontinue or alter therapy on their own.

Your Thoughts?
How do you approach tapering RA treatment in your practice? Answer the polling question and post your thoughts in the comments section below.

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