Maybe, if a patient is lucky enough to be in remission, we should just be happy.
What to do with patients in remission was never an issue in my first decade in rheumatology, because hardly anyone ever got there and generally everyone was very pleased when they did.
I still had a few episodes that taught me a couple of key rules in the management of rheumatoid arthritis.
The first is, “if it ain’t broke, don’t try and fix it” – i.e. if someone is lucky enough to be in remission, and their corticosteroid dose is at a level regarded as safe, then it is best to resist all temptation to change as it will usually end badly if you give in.
The second rule, which came with the advent of biologic therapies, was that rheumatoid arthritis should be treated like a good husband – i.e. kept firmly under the thumb and given no freedom, because patients with grumbling disease always got worse in my experience, thus a treat-to-target approach is a good thing.
Those of you with some interest in history may remember that Australia did a trial of this in the early 2000s, funded by Sanofi, and it showed no benefit because we were already pretty aggressive at getting disease under control.
Tapering was always a bit opaque in my view but has certainly spawned a lot of research endeavour. I could understand the need/desire to decrease prednisone to safe doses (a daily dose of 3mg is my definition for this in most, but not all, patients).
Nearly all the biologics are steroid sparing, so this is an achievable aim in most patients.
Tapering MTX seemed frankly silly. This drug is needed with most modern therapies (apart from JAKs and IL-6 blockers) for best efficacy and has a substantial protective effect on mortality in multiple studies, so it should be among the last to be stopped (but, of course, this is not what our patients want).
Then there is the drive to taper biologics and targeted synthetics primarily driven by cost in my view. Every trial in rheumatoid arthritis shows that tapering/cessation of biologics virtually always results in a higher flare rate so why would you do it?
The only exception in my view is seronegative rheumatoid arthritis in remission for longer than six months. This group have an 80% chance of coming off therapy, but no-one else has, and very few of these are actually on biologics as they usually have milder disease.
In psoriatic arthritis and ankylosing spondylitis, the data is a bit less clear cut, and I am sure many of you have patients who have successfully spread out dosing given we have no option to decrease dose while keeping the frequency the same. The PBS doesn’t like either of these approaches, wanting an assessment every 6 months regardless of how long the script lasts, but why would they be worried about lowering health costs?
So, in this context, it was refreshing to see the recent high-quality trial in the Annals of the Rheumatic Diseases.
They randomised a treat-to-target approach to decreasing TNF use by progressively increasing treatment interval in those with psoriatic arthritis and axial spondyloarthritis in low disease activity.
This essentially confirmed a very small worsening in disease activity (a 5% difference, which was non-inferior, and maybe some worsening of radiographic progression in psoriatic arthritis) with an almost halving of TNFi usage.
They claim this will decrease cost, patient burden and adverse events, but I only really agree with the first.
This seems achievable in clinical practice, and I think it warrants consideration in those with milder disease who are doing well. With all the others, achieving remission is a great outcome – so be happy.
Reference: Michielsens CA, den Broeder N, van den Hoogen FH, et al. Treat-to-target dose reduction and withdrawal strategy of TNF inhibitors in psoriatic arthritis and axial spondyloarthritis: a randomised controlled non-inferiority trial. Annals of the Rheumatic Diseases 2022;81:1392-1399.
