Lowering the drug dose might be more effective than trying to cease it altogether Evidence supporting dose-tapering for patients with well-managed psoriatic arthritis is mounting, with experts claiming the regimen is unlikely to jeopardise disease remission in the majority of patients and will save the health system money. Recent years have brought about a greater […]
Lowering the drug dose might be more effective than trying to cease it altogether
Evidence supporting dose-tapering for patients with well-managed psoriatic arthritis is mounting, with experts claiming the regimen is unlikely to jeopardise disease remission in the majority of patients and will save the health system money.
Recent years have brought about a greater understanding of psoriatic arthritis, along with innovative new medicines. More than ever, early diagnosis is enabling patients to access effective management in the earlier stages of their disease.
Thanks to this, an increasing number of patients are achieving sustained clinical remission, prompting questions about when and how to taper or stop treatment.
UK rheumatologist Dr Laura Coates, in a presentation titled, Tapering in PsA – to do or not to do?, at the EULAR conference in Amsterdam earlier this year, provided an optimistic reflection on the literature.
Tapering the dose was successful for between 60% and 90% of patients who were well, and in most cases, the remission status was sustained for over a year.
“This isn’t 60% to 90% of our entire population but it’s 60% to 90% of people who are meeting these criteria and being considered for tapering,” she said.
In addition, it appears lowering the dose might be more effective than trying to cease the drug altogether.
Currently, the research indicated discontinuing treatment completely led to flares in between 45% and 90% of patients, with the average time to flare ranging broadly, from weeks to up to a year, the UK psoriatic arthritis expert explained.
“This probably is not the way to go in the majority of patients,” she said.
There were some predictors for who would have flares. Women and smokers appear to flare more often.
But Dr Coates said the main focus for determining eligibility for tapering should be on disease activity. Better disease control and lower DAS28 scores boded well for avoiding flares.
“We can’t change the gender of our patients, but we can look at how deep a remission and disease control we achieve and for how long, before we then start to withdraw therapy.”
There is some evidence suggesting ultrasound can help shed light on subclinical disease and give indications of disease control.
“But we still need to individualise this to each patient and have, certainly at the moment, a very honest discussion about what the data show and where the data are lacking.”
Should a patient begin to flare again after being discontinued or tapered down off the drugs, Dr Coates said that nearly all the studies show the disease could be recaptured.
“Even when people have flared, when you get them back on to the full dose of therapy, the vast majority have got back to their normal outcomes.”
Nevertheless, one UK study found that patients largely recaptured their disease activity by six months, but those who had flared had a higher DAS[28 score] at 24 weeks than those who had not flared.
“So they had improved back to a level, but probably not quite where they would have been if their therapy had not been stopped.”
As well as saving patients from as many injections, reducing the dose of these expensive drugs has the potential to save the healthcare system substantial amounts of money.
Because tapering often involved stretching the dosing interval out to double or even three times its initial length, healthcare costs could be halved or more, Dr Coates said.
When it came to adverse events, the few studies that had investigated these regimens had been mostly underpowered, she explained.
So far, the literature hadn’t shown any obvious safety improvements, but there was obviously a theoretical risk reduction, Dr Coates said.
Overall, patients tended to prefer treatments options which involved fewer injections and were less expensive.
Patients who were older, male, had a longer disease duration, had axial disease rather than psoriatic arthritis and who were receiving injectables, such as biologics rather than conventional DMARDs, were more likely to agree to trial tapering or stopping, Dr Coates said.
In her experience, patients were sometimes reluctant to try discontinuing or tapering as part of a research trial, preferring to wait until there was more evidence, she added.
