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ACR/ARP 2020: New Data on Tapering RA Medications During Remission

Jonathan Kay, MD

Professor of Medicine and Population and Quantitative Health Sciences
Timothy S. and Elaine L. Peterson Chair in Rheumatology
Division of Rheumatology
Department of Medicine
University of Massachusetts Medical School
Division of Rheumatology
Department of Medicine
UMass Memorial Medical Center
Worcester, Massachusetts

Jonathan Kay, MD, has disclosed that he has he has received consulting fees from AbbVie, Boehringer Ingelheim, Celltrion, Jubilant Radiopharma, Pfizer, Samsung Bioepis, Sandoz, Scipher Medicine, and Union Chimique Belge, and funds for research support from Gilead Sciences, Novartis, and Pfizer.

View ClinicalThoughts from this Author

Released: December 18, 2020

For patients with RA who achieve clinical remission, there has been debate about whether and how to taper their medication(s). Current ACR guidelines recommend that both disease-modifying antirheumatic drugs (DMARDs) and biologic therapies can be tapered but caution against discontinuing therapy, as it is likely to result in disease flares.

Outstanding questions remain for rheumatologists devising a tapering strategy, including which medication should be tapered first and which medications should not be tapered. New data from the virtual ACR Convergence 2020 have offered clear answers to some of these questions. 

In the multicenter, open-label, noninferiority phase IV ARCTIC-REWIND trial, 92 patients with RA who were in remission on stable TNF inhibitor therapy, with or without a conventional synthetic DMARD, were randomized to either taper or continue the TNF inhibitor (while continuing any conventional synthetic DMARD comedication). The primary endpoint was the frequency of disease flares over 12 months.

The main finding was that patients who tapered their TNF inhibitor were nearly 60% more likely to experience a disease flare compared with those who continued taking a TNF inhibitor. This trend was observed regardless of whether or not they were also being treated with a conventional synthetic DMARD.

This outcome was surprising in the context of previous studies, such as the PRESERVE and PRIZE trials, which suggested that patients with RA in low disease activity or remission could successfully reduce their etanercept dose—but not discontinue etanercept completely—and maintain control of disease activity.

Also at ACR/ARP 2020, we saw new data from the phase III SEAM-RA study. In this trial, 371 patients with moderate-to-severe RA who were in Simplified Disease Activity Index remission on etanercept and methotrexate were randomized to stop either etanercept or methotrexate or to continue treatment with both. The primary endpoint was the frequency of patients who remained in remission at Week 48.

The study demonstrated that patients were more likely to remain in remission if they stopped methotrexate and continued etanercept than if they stopped etanercept and continued methotrexate. This finding is practice changing, as one might have been inclined to taper and discontinue the more expensive TNF inhibitor and maintain patients on methotrexate alone. However, these data support the practice of discontinuing methotrexate and maintaining RA patients who are in clinical remission on the TNF inhibitor alone with continued control of disease activity. 

Taken together, these studies should modify current guidance to suggest that patients with RA in low disease activity or remission should continue TNF inhibitor therapy while tapering and possibly discontinuing methotrexate. This approach is especially useful when treating patients who experience side effects on methotrexate, such as hair loss.

Your Thoughts?
How will new data from ACR/ARP 2020 influence your approach to tapering therapy for patients achieving remission? Answer the polling question and join the conversation by posting a comment in the discussion section. For more detailed coverage of these and other studies from ACR/ARP 2020, download capsule summaries and reuse the slides in your own presentations.

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