Rheumatoid Arthritis (RA) is a chronic, immune-mediated systemic disease, affecting approximately 2% of individuals worldwide and has a substantial impact on the lives of approximately 600,000 people in the UK. Sub-optimal treatment results in substantial joint pain, disability, adverse social consequences and increased mortality. Thus, RA is a disease of considerable socioeconomic burden, with direct and indirect healthcare costs reaching £>2 billion per annum.
The last decade has however seen many advances in the treatment of rheumatoid Arthritis (RA), with many more patients achieving a state of remission (absence of signs and symptoms) than ever before. This is down to earlier diagnosis, the increasing availability of targeted therapies (e.g. biologics) and following strict treat-to-target regimens to tightly control inflammation. Following the achievement of remission, these patients are currently, typically followed up on an annual basis (as per national guidance). Once remission is achieved, current practice is to continue drugs (same dose) long-term to maintain this state, but this may not always be desirable, nor necessary.
Chronic immunosuppressive therapy, particularly bDMARDs, can be associated with adverse events e.g. dose-dependent increased risk of infections and malignancy. There is also the major issue of cost (in excess of £6k pa). In addition, patients who are well frequently express a desire for reduced therapy. Based on extensive research in the field, International guidance has advised to slowly reduce, with the aim to stop treatment in patients who are well. However there is no sufficient evidence yet to help inform such decision to taper biologics in clinical practice. Thus, tapering (towards stopping) bDMARDs in patients in remission is a key management issue. In practice, experience with tapering is mainly related to tumour necrosis factor inhibitors-TNFis. Rationally, a lower dose of TNFi should be able to maintain response in patients in remission as levels of the target molecule (TNF) are reduced in successful therapy. Some data show that tapering is feasible in a proportion of patients in remission however, not in all and the ideal patient profile is unknown.