Is optimizing biologic treatment effective in rheumatoid arthritis?

This paper studied optimization of biologic treatment in rheumatoid arthritis (RA).

Biologics are a new and popular treatment for RA. Biologics work by blocking certain processes in the immune system. However, even though the drugs are effective, patients in remission (disappearance of symptoms) often stop taking biologics. To date, there is not enough evidence to recommend stopping treatment. It is unclear whether optimizing biologic treatment (making treatment more effective by changing the dosage) is better compared to stopping treatment completely.

The authors evaluated the effective optimization of biologic treatment in RA patients. 

64 patients with RA who were treated with biologics and undergoing optimization were studied. The type of biologics studied include TNF antagonists (infliximab; Remicade, etanercept; Enbrel, adalimumab; Humira, certolizumab; Cimzia), tocilizumab(Actemra) and abatacept(Orencia). Patients treated with rituximab (Rituxan) were not included in the study. The average age of patients was 61. 82.8% of patients were women. On average, patients had RA for 10.6 years and prior time in remission was 19 months. Average follow-up time was 15 months.

Patients followed an optimization program, where the biologic dose was decreased and the time between doses was increased. The authors recorded the number of swollen and tender joints and evaluated patient's DAS28-ESR value. DAS28-ESR refers to the disease activity score, which measures how active rheumatoid arthritis is in 28 joints in the patient. A low DAS28-ESR value indicates low disease activity. The main outcome was time to relapse. This was defined as an increase in DAS28-ESR score or increase in dose or frequency of medication.

Rates of relapse were 9.8% at 6 months, 31.4 % at 12 months and 44.6 % at 18 months. Average time to relapse was: 10 months for abatacept, 19 months for adalimumab, 15.5 months for etanercept, 16.5 months  for infliximab and 10 months for tocilizumab.

Patients who relapsed, however, responded once full dose of biologic was received. The average DAS28-ESR at relapse was 3.44 and the average DAS28-ESR after going back to full dose was 2.52.

In summary, the authors concluded that optimizing RA treatment by lowering the treatment dose is effective, resulting in a low percentage of relapses. 

This was a relatively small and short study, potentially warranting longer term studies.