What is the approach to deprescribing in patients with Rheumatoid Arthritis (RA)?

From the Guidelines

Deprescribing in rheumatoid arthritis patients should follow a cautious, individualized approach based on sustained disease remission, as recommended by the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. For patients who have maintained remission (defined as DAS28 score <2.6 or equivalent measures) for at least 6-12 months, medication reduction can be considered. Begin by tapering the highest-risk medications first, typically glucocorticoids like prednisone, which should be reduced by 1-2.5mg every 1-4 weeks until discontinuation. For conventional synthetic DMARDs like methotrexate, leflunomide, or sulfasalazine, consider dose reduction by 25-50% every 3-6 months while monitoring for disease activity. Biological DMARDs such as TNF inhibitors (adalimumab, etanercept) or JAK inhibitors (tofacitinib, baricitinib) can be tapered by extending the dosing interval or reducing the dose. Throughout the deprescribing process, patients should be monitored closely with regular clinical assessments and inflammatory markers (ESR, CRP) every 1-3 months. If disease flares occur (increased joint pain, swelling, or elevated inflammatory markers), promptly reinstate the previous effective medication regimen. This approach minimizes medication risks and side effects while maintaining disease control, as prolonged exposure to immunosuppressants increases infection risk and other adverse effects, while glucocorticoids can cause osteoporosis, diabetes, and cardiovascular complications. Key considerations in the deprescribing process include:

• Patient education and shared decision-making 1
• Regular monitoring of disease activity and adjustment of treatment as needed 1
• Gradual tapering of medications to minimize risk of disease flare 1
• Consideration of individual patient factors, such as comorbidities and medication side effects 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Deprescribing in Patients with Rheumatoid Arthritis

• The approach to deprescribing in patients with Rheumatoid Arthritis (RA) is not directly addressed in the provided studies, as they focus on the efficacy and safety of combination therapies with methotrexate, sulfasalazine, and hydroxychloroquine 2, 3, 4, 5.
• However, the studies suggest that combination therapy with methotrexate, sulfasalazine, and hydroxychloroquine is more effective than monotherapy or double therapy in reducing disease activity and improving functional outcomes in patients with RA 3, 5.
• The retention rates of these combination therapies are also reported, with one study finding that patients on triple therapy remained on treatment longer than patients on double therapy, although the difference was not statistically significant 2.
• Another study found that the triple combination of methotrexate, sulfasalazine, and hydroxychloroquine was well-tolerated and had superior efficacy to double combinations of methotrexate and sulfasalazine or methotrexate and hydroxychloroquine 5.
• The assessment of disease activity, structural damage, and function in RA is crucial in determining the need for deprescribing or adjusting treatment regimens 6.
• While the provided studies do not directly address deprescribing rates, they suggest that combination therapies with methotrexate, sulfasalazine, and hydroxychloroquine are effective and well-tolerated in patients with RA, which may inform deprescribing decisions 2, 3, 4, 5.

Current Rates of Deprescribing

• There are no direct reports on the current rates of deprescribing in patients with RA in the provided studies.
• However, the studies provide insight into the efficacy and safety of combination therapies, which may be useful in informing deprescribing decisions 2, 3, 4, 5.
• Further research is needed to determine the current rates of deprescribing in patients with RA and to develop evidence-based guidelines for deprescribing in this population.