COMMENTARY

Rheumatology Advances to Know From 2015

Kevin Deane, MD, PhD

Disclosures

December 23, 2015

In This Article

More Treatment Findings in RA

As to how to predict ahead of time which patients can undergo medication tapering without later flares, in the RETRO study, Haschka and colleagues[2] found that the presence of antibodies to citrullinated proteins (ACPAs) was associated with increased relapse. In a follow-up study,[4] they found that using a multibiomarker disease activity score improved prediction of relapses.

These findings suggest that RA therapies may be reduced and remission maintained in a subset of patients. However, as discussed in a comprehensive 2014 Cochrane review regarding anti-TNF down-titration and discontinuation in RA,[5] these findings need more exploration before broad evidence-based clinical practices guidelines can be developed, although in the 2015 American College of Rheumatology RA guidelines, tapering of medications in patients in remission is recommended for consideration.[6] In particular, the longer-term cost-effectiveness and clinical impact of medication reduction strategies in RA needs evaluation in well-designed and implemented studies.

Also, although some studies suggest that such biomarkers as ACPAs and rheumatoid factor (among others) can identify patients who are at risk for flares after taper,[4,7] much more needs to be learned about how to accurately predict which can patients can undergo medication tapering without experiencing a flare. In particular, given van Nies and colleagues[8] finding that improved rates of disease-modifying antirheumatic drug-free remission in RA were in large part related to a shorter duration of symptoms before initiation of therapy, we need to consider how getting patients with early RA to therapy can be integrated into plans to treat to remission, then taper therapy.

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