Down-titration and withdrawal of the biologic agents in rheumatoid arthritis: a review of literature

Abstract

ABSTRACT Objectives: To describe clinical indications, treatment outcomes of down-titration and withdrawal the biologic agents in rheumatoid arthritis. Subjects and methods: An electronic search of PubMed and Cochrane Database of Systematic Review was last executed on 10th August 2021 and the results were limited to references published from January 2016 to December 2020 in the English language. The electronic search combined the term “rheumatoid arthritis” and a term for down-titration, i.e., rheumatoid arthritis and dose decreasing or dosage decreasing. Results: We included 27 studies in our scoping review. Most of studies used the DAS28-CRP or DAS28-ESR score to identify low disease activity (<3.2) or clinical remission (<2.6) or deep remission (<2.0) required for tapering and these studies design included patients who achieved low disease activity or clinical remission for at least 6 months. Dose-tapering is always associated with the risk of flare after a period of time, but most of relapsing patients regained sustainability of low disease activity or clinical remission after reinstating biologics with standard dose. Disease-activity-guided dose optimization results in large cost savings per patient per year and no or a small loss in QALYs. DAS28-CRP (ESR) cut-off at baseline, presence of RF or anti- CCP antibody, dosage of methotrexate… was used to predict success or failure of tapering. Keywords: Rheumatoid arthritis, dose-tapering, biologics, remission.