Tapering and sometimes discontinuation of DMARDS is possible in people with rheumatoid arthritis who achieve sustained remission, hinting at the possibility that the disease could be cured.
INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that causes pain and disability. It can also affect internal organs. Rheumatoid arthritis is more common in older people, but there is also a high prevalence in young adults, adolescents and even children, affecting women more frequently than men. Disease modifying antirheumatic drugs (often referred to as DMARDs) are a type of medicine used to treat rheumatoid arthritis. The term DMARD includes traditional drugs such as methotrexate, as well as newer biologic therapies. DMARDs can prevent joint damage and help people to control their disease. With increasing understanding of rheumatoid arthritis and more available treatment options, today patients are often treated earlier and get better results. Effective, early treatment means that patients with rheumatoid arthritis often achieve remission, where they have no clinical signs or symptoms. There is a growing desire for patients to stop taking their medicine once they have achieved remission, but this needs to be done gradually and under the supervision of a doctor. This procedure is called tapering.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors aimed to provide an overview on what is known about the gradual tapering and withdrawal of DMARDs in people with rheumatoid arthritis who have achieved remission.
WHO WAS STUDIED?
This is a review article that looks at people with rheumatoid arthritis. This means that no special study or literature search was undertaken. The authors summarised their understanding of the current evidence for tapering and withdrawal of DMARDs.
WHAT WERE THE MAIN IDEAS IN THE REVIEW?
The authors introduce the idea of tapering and withdrawing DMARDs, and summarise the key studies that support these ideas. The observations suggest that – in some people with rheumatoid arthritis – treatment may now lead to cure rather than only suppression of the disease, and some studies have suggested that over half of people remain in low disease activity or remission for at least 1 year after stopping or tapering biologic therapies for their rheumatoid arthritis.1–3 The article provides guidance for doctors about when to taper and withdraw these medicines in their patients. It suggests that tapering should be considered if people are in remission for at least 6 months without any changes to their treatment, and as long as they are not using any steroid medicines in addition to their DMARD. The article also gives some guidance about what would be needed in order to taper DMARDs in real-life situations outside clinical trials. This included clinical measurements as well as the use of imaging techniques and biomarkers to predict the chance for relapse of the disease and to monitor patients accordingly. If patients relapse once they have stopped taking their DMARD, it is possible to restart treatment again with good effects.
ARE THESE FINDINGS NEW?
Yes, this is the first time that a comprehensive review has been written on this topic. It gives a broad perspective on tapering and withdrawal of DMARDs.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The authors hope to be able to develop a guidance for DMARD tapering and withdrawal in people who have achieved remission. This is important because it will help to avoid people being over-treated (receiving too much medicine that they do not need). They also hope to be able to provide a strategy for a potential “exit-strategy” that will stop people needing to receive drugs for their whole life.
WHAT DOES THIS MEAN FOR ME?
At present, rheumatoid arthritis is considered to be a disease with no cure, but that could change. If you have rheumatoid arthritis, this article suggests that under certain circumstances, and if you have had a very good response to treatment and are in remission, it may be possible to gradually taper and even stop DMARD treatment without experiencing a flare of your disease. Whether this is possible will depend on your own personal factors and the drugs you are taking. It is very important that you do not attempt to stop your treatment yourself without talking to your doctor.
FURTHER READING
EULAR recommendations for management. Available at: http://www.eular.org/recommendations_management. cfm
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Date prepared: August 2016
Summary based on research article published on: 3 June 2016
From: Schett, G. et al. Tapering DMARD therapy in rheumatoid arthritis – Current evidence and future directions. Ann Rheum Dis 2016;75:1428–37.
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