Maintain or Taper Biologic Therapies
by Dr. David Borenstein M.D. 5/2020
A constant question faced by rheumatoid arthritis and ankylosing spondylitis patients is should my therapy be decreased if my disease is doing well. A part of that consideration is the increased risk of serious infections, serious adverse events, malignancies, cardiovascular events, or deaths presumed to occur with continued use of biologic therapies.
A meta-analysis (review of multiple studies) was reported evaluating this specific concern. Studies were included if rheumatoid arthritis or spondyloarthritis patients were in remission or a low disease activity state. Of 1957 studies, 13 controlled trials (9RA and 4SPA) were included. Tapering group (TG) had 1174 patient-years studied while the steady care group (SG) had 1086 patient-years. Serious infections occurred in 1.7/100 patient-years in TG versus 2.6/100 patient-years in SG. Serious adverse events occurred in 7.4/100 patient-years in TG versus 6.7/100 patient-years in SG. Both of these were not statistically different. The risk of malignancies, cardiovascular events and deaths were not different in TG and SG. Subgroup analysis of the RA and spondyloarthritis group found no differences between these illnesses.
The results of this meta-analysis should be reassuring to RA and spondyloarthritis patients taking biologic disease modifying drugs or Janus kinase inhibitors. The first goal of therapy is to control disease. The use of those agents may cause adverse events. Patients constantly weigh the benefits of their therapy and the risks to decide on remaining on a therapy. In some circumstances, patients feel compelled to decrease effective therapy because of toxicities. The meta-analysis reports that remaining on therapy is unassociated with increased risk of serious adverse events.
Therefore, a decision about continuing or discontinuing effective therapy has more to do with convenience of no further injections and decreased drug costs as opposed to improved safety. The risk of tapering therapy is the appearance of a disease flare. These parameters need to be considered when making the therapeutic choices for a patient’s care.
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- Vinson D et al. Impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and adverse events of special interest in patients with rheumatoid arthritis or spondyloarthritis: a systematic analysis of the literature and meta-analysis. Arthritis Rheum Ther 2020;22:97 doi.org/10.1186/s13075-020-02188-x