Maintenance therapy over dose reduction: which one to choose in RA remission?

The authors analyzed the effect of dose reduction in rheumatoid arthritis patients (RA) in remission (disease recovery). 

Disease-modifying antirheumatic drugs (DMARDs) are safe and effective treatments in patients with RA. DMARDs can be chemical or biological. The objective of these treatments is to achieve remission. Once the patients start to recover, treatment step-down strategies can be attempted. A step-down strategy can include either a reduction in treatment dose or a complete discontinuation of treatment. In the case of biological DMARDs, discontinuation of treatment after remission is more frequent. However, a risk of relapse with an increased risk of joint damage has been reported in some patients within one year of discontinuation. Reducing the dose of certain biological DMARDs resulted in non-significant risks of relapse and joint damage.

Further analysis is needed on the effect of reducing treatment dosage for RA patients in remission. 

The authors aimed to compare the effect of dose reduction (tapering) to maintenance therapy (stable dose throughout) in RA patients in remission.

137 patients participated in this 18-month study. 73 patients in group 1 received etanercept (Enbrel) or adalimumab (Humira) as maintenance therapy for at least one year, or in combination with other DMARDs for at least 6 months. 64 patients in group 2 received etanercept or adalimumab with a 50% dose reduction every 3 months until treatment was completely stopped. Disease Activity Score (DAS28) was compared between the two groups. DAS28 is an assessment used to measure the progress and improvement of RA by examining 28 joints.

In group 2, 39.1% stopped treatment altogether. 35.9% received a dose reduction and 20.3% maintained full doses throughout this study. There was a difference of 19% in DAS28 scores between the two groups. 76.6% of patients in group 2 experienced a relapse (return of disease) compared to 46.5% in group 1. The average time to relapse was 9 months in group 2 compared to 18 months in group 1. There was no difference in progression of joint damage between the two groups. 

The authors concluded that dose reduction and maintenance therapy did not produce similar outcomes for RA patients in remission. They also found that there was an increased risk of relapse in patients who underwent dose reduction (tapering).  

Studies with larger patient populations are needed to understand the effectiveness of step-down treatment strategies.