A new study presented recently at the 2017 Annual Meeting of the American College of Rheumatology identifies four factors that may predict which rheumatoid arthritis (RA) patients might successfully taper the dose of their biologic medication.
Although biologics are highly effective in controlling RA and its symptoms, patients in some cases prefer not to use them. Past studies have shown that it is possible to taper and even stop the medication in certain patients who are in remission once they have been successfully treated with one of these drugs.
Reducing the dose of biologics is attractive for several reasons. These drugs are quite costly for patients and the health care system. Also, higher doses of biologics are more likely to lead to side effects, some of which can be serious, such as infection.
“The idea of down-titration [dose reduction] of biologics might result in reduction in costs and dose-dependent side effects,” says lead study author Takaaki Komiya, MD, a researcher at Yokohama City University Graduate School of Medicine in Japan.
Dr. Komiya and his colleagues wanted to find out which patients are best suited for tapering of biologics and what factors are more likely to predict success.
The study looked at two groups of patients with rheumatoid arthritis who were on one of seven biologics – abatacept (Orencia), adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), or tocilizumab (Actemra) – for more than six months. One group of 255 patients was kept on standard dose treatment while the second group of 92 patients had their medication tapered.
The researchers did not use a precise protocol for tapering; while some patients received a reduced dose of their biologic, others had the interval between doses extended. “Timing and method of tapering were dependent on shared decision [making] between the patients and rheumatologists,” Dr. Komiya explains.
He and his colleagues found that the following factors predicted successful tapering of a biologic: being on a biologic for the first time; younger age; not taking oral corticosteroids; and lower blood levels of C-reactive protein (CRP), a marker of inflammation.
“Tapering of a biologic DMARD [disease-modifying antirheumatic drug] is widely used in clinical practice, but some patients experience disease relapse. So it is important that this study demonstrated the possibility that patients who succeed in down-titration of [biologics] have some key features,” Dr. Komiya emphasizes. “Patients who have these characteristics could proactively suggest to their doctor to reduce the dose of biologic DMARD.”
He concludes, “This research is only the beginning [of the search for factors associated with successful down-titration]. If future research identifies more relevant predictive factors, physicians will probably be encouraged to make a greater effort to down-titrate their patients.”
Paul Sufka, MD, a rheumatologist at University of Minnesota in St. Paul, who was not involved in the study, comments on the findings: “Patients are highly interested in weaning down biologic medications. They are typically very expensive and come with an increased risk of infection,” he says.
“Since rheumatoid arthritis can be difficult to treat, physicians are often reluctant to have patients decrease their medications, fearing their disease will flare and they won’t be able to get it back under control,” Dr. Sufka adds. Knowing which factors are associated with less risk of flaring after tapering “can help predict whether they might be successful at weaning their medication, or if they would likely be better off staying on their current medication.”
Author: Alice Goodman for the Arthritis Foundation