medwireNews: A systematic review has identified several factors predicting successful discontinuation of biologic DMARDs in people with rheumatoid arthritis (RA), including low disease activity and good physical function.
Previous studies have demonstrated “effective withdrawal of b [biologic]DMARDs and ts [targeted synthetic]DMARDs in RA patients and the updated treatment recommendations of the EULAR now consider tapering of bDMARDs in patients with persistent remission,” say Helga Radner (Medical University Vienna, Austria) and colleagues.
However, “to this day there is no clear consensus on if, when, or in whom bDMARDs or tsDMARDs should be discontinued,” they add.
The systematic review included 34 studies involving a total of 5724 people with RA. In all, 2779 patients discontinued biologic DMARDs, most commonly tumor necrosis factor inhibitors, after achieving remission or low disease activity, while 54 patients from one study discontinued the Janus kinase inhibitor tofacitinib.
Radner and team report in Rheumatology that maintaining remission or low disease activity “is still challenging for most RA patients,” but say “the included studies show that a significant number of patients may sustain their good state.”
Indeed, 38.1% of patients remained in remission and 45.9% remained in low disease activity at an average of 21.0 months after treatment discontinuation. Average rates of remission were higher in studies where biologics were tapered before being discontinued compared with those where biologics were stopped without prior tapering, at 44.6% versus 31.8%.
Lower disease activity at the time of discontinuation was identified as a predictor of successful biologic discontinuation based on the results of 13 studies, while six studies revealed better physical function as a predictor. Other factors associated with successful discontinuation were shorter disease duration, low levels or the absence of rheumatoid factor or anti-citrullinated protein antibodies, low levels of C-reactive protein, low erythrocyte sedimentation rate, and low measures of disease activity on imaging.
“These predictors may inform clinicians in their decision making in patients who are considered for a potential bDMARD discontinuation,” write the investigators.
They say that the one study investigating tofacitinib identified low rheumatoid factor titers (<32 U/mL) as a predictor of successful discontinuation, but caution that the study had high risk for bias, “limiting interpretation of results.”
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