Reducing the Dose of a Biologic is Called Tapering but Does it work?

In a study reported in the Annuals of Rheumatic Diseases (2018), showed that it was possible to taper successfully over time. This study showed in patients with RA being treated with Baricitinib from 4 gm to 2 mg daily was successful for certain patients. Patients were concurrently on methotrexate (MTX) with/without glucocorticoids, tapering to Baricitinib 2 mg dose led to statistically significantly lower disease activity rates up to 48 weeks follow-up. Up to two-thirds of the patients with RA who relapsed to a higher disease activity could regain their low disease activity or remission within 24 weeks after rescue with Baricitinib 4 mg dose.

This indicates that patients on 4 mg daily who showed very reduced disease activity and who have taken this medication for one year or more can achieve successful dose tapering while continuing on their other regular medications.
This is an important finding since patients frequently consider and try RA medication tapering or discontinuation. The cost of life-long therapy with biologic or Janus kinase inhibitors in RA is high. This study provides robust data to support Baricitinib tapering in patients who desire it, with some risk of returning to a higher disease activity state.  However, in a systematic review of 52 papers of biologics across various rheumatic conditions and concluded that remission is typically not sustained in patients who discontinue biologic therapy. The relapse rates and flare in people discontinuing biologic was moderate to high in people with early RA (48%–54%) and established RA (2%–84%).  In many cases, an acceptable disease activity could be regained on retreatment. A key limitation of the current evidence is the inability to predict which patient with RA will succeed in DMARD/biologic tapering without flare and without the loss of current low disease activity state.

The 2015 American College of Rheumatology (ACR) defined DMARD/biologic tapering as scaling back one medication at a time, by reducing dose or dosing frequency and recommended conducting it slowly and carefully, watching for increased disease activity and flares.  The ACR guideline also recommended that even in remission, all the drugs should not be stopped at the same time.

Ref: Annals of Rheumatic Diseases 2018
Derived from an Editorial in the Annals of Rheumatic Disease, 2018: Tapering Janus kinase inhibitors in rheumatoid arthritis with low disease activity or remission: reality or dream? By Jasvinder A. Singh.