When can treatment be tapered for patients with Rheumatoid Arthritis (RA) who have achieved sustained remission or low disease activity?

When to Taper Treatment for Rheumatoid Arthritis

Treatment tapering for rheumatoid arthritis (RA) should be considered only after a patient has achieved persistent remission, with tapering of biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) considered first, followed by conventional synthetic DMARDs (csDMARDs) if remission is maintained.

Criteria for Considering Treatment Tapering

Prerequisites for Tapering

• Persistent remission defined as:
  • Disease Activity Score 28-CRP (DAS28-CRP) <2.3 or Simplified Disease Activity Index (SDAI) ≤3.3
  • Remission must be sustained for a significant period (at least 6-12 months)
  • Glucocorticoids should be tapered and discontinued first before considering DMARD tapering 1

Sequence of Tapering

1. First step: Taper glucocorticoids completely
2. Second step: Consider tapering bDMARDs or tsDMARDs (if patient is on these medications)
3. Third step: Consider cautious reduction of csDMARD dose only after long-term sustained remission

Evidence-Based Tapering Approach

Tapering bDMARDs/tsDMARDs

• Tapering of bDMARDs should be considered first, especially when combined with a csDMARD (Level 1b evidence, Grade A recommendation) 1
• Tapering means either dose reduction or prolongation of intervals between applications, not complete discontinuation 1
• Most evidence exists for TNF inhibitors, but the principle applies to other biological agents 1

Tapering csDMARDs

• Only consider after sustained long-term remission (Level 2b evidence, Grade B recommendation) 1
• Should be a shared decision between patient and physician 1
• Cautious reduction rather than complete discontinuation is recommended

Risk Assessment and Monitoring

Risk Factors for Relapse After Tapering

• Longer disease duration 2
• Higher disease activity scores even within remission range 2
• Higher power Doppler scores on ultrasound 2
• Presence of anti-citrullinated protein antibodies (ACPA)

Monitoring During Tapering

• Regular clinical assessments every 3 months
• Consider ultrasound monitoring as it may detect subclinical inflammation 2
• Be prepared to return to previous dosing if disease activity increases

Outcomes of Tapering Strategies

Success Rates

• Complete DMARD discontinuation has high relapse rates (56-87% at one year) 3
• Dose reduction strategies are more successful than complete discontinuation 4
• In the RETRO trial, remission was maintained in:
  • 81.2% of patients continuing full-dose treatment
  • 58.6% of patients on 50% dose reduction
  • 43.3% of patients who stopped DMARDs 4

Management of Relapse

• Most patients who relapse after tapering can regain remission with reintroduction of the previous treatment regimen 4
• Risk of structural damage progression with tapering is minimal 3

Important Caveats

• Tapering should never be mandated but offered as an option to appropriate patients
• The decision to taper should be a shared decision between patient and rheumatologist
• Low disease activity (LDA) should not be considered an adequate state for initiating DMARD tapering 5
• Tapering must be conducted slowly and carefully with vigilant monitoring for increased disease activity
• Physical function may temporarily worsen during tapering but generally returns to baseline with treatment reintroduction if relapse occurs 6

By following these evidence-based guidelines for tapering RA treatment, clinicians can help reduce unnecessary medication exposure while maintaining disease control in appropriate patients who have achieved sustained remission.