Tapering biologics only likely to work in early disease: expert

The strategy of tapering the doses of biologics in people with rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis is only likely to work in early disease, a UK expert has told the limbic.

Professor Christopher Edwards, a consultant rheumatologist from the University Hospital Southampton NHS Foundation Trust, UK, was speaking to the limbic following the publication of a literature review in Rheumatology involving 52 papers  that addressed dose tapering across a range of rheumatic diseases.

He said the review, which he co-authored, revealed there was no uniform approach when it came to deciding whether to maintain, titrate down or withdraw the dose of biologic treatment.

There was also wide variability in the disease and patient characteristics used by clinicians to decide when to taper doses and often no clear monitoring approach in place.

According to Professor Edwards further studies will be needed to establish the best clinical practice, but judging by the results of the literature review it seemed clear that stopping biologic therapies in patients with established disease ended in failure.

For example, flares were reported in as many as 84% of cases within a year of discontinuation.

However, Professor Edwards said that while it might not be appropriate to stop biologic therapy in established disease, there may be a basis for careful and controlled dose reduction in some patients if they have responded well on re-introduction of treatment.

“It appears from a number of the studies that some patients are able to titrate the dose of their biological therapy down and be sustained in remission or low disease activity, at least in the short to medium term.

“At present US looks like a pretty good way of helping to determine which patients are at risk of flaring and can be used to monitor disease activity.

“In the future, all the information coming from stratified medicine studies with US-guided biopsies etc, may allow us to subdivide patients more accurately,” Professor Edwards told the limbic.

He suggested that two defined treatment phases could exist: a first full-dose remission-induction phase; then a remission-maintenance phase with reduced dosage or frequency.

“It would be great to induce remission in patients with biological therapies or combinations of DMARDS and then reduce the doses or numbers of therapies we use.. It looks likely that this will only really work for patients with early disease.

“It would also need work on the health economic models (or cheaper therapies through the adoption of biosimilars) to allow the use of biological therapies early in the disease course,” he added.

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