Article Text

AB0483 Biological Treatment Switching and Withdrawal: A Review of Rheumatoid Arthritis Guidelines
  1. T. Piazza,
  2. F. Tonin,
  3. A. Wiens,
  4. R. Pontarolo
  1. Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil


Background The setting of biological agents as part of Rheumatoid Arthritis (RA) therapeutic tools creates enthusiasm in clinical interventions due the possibility of action in specific inflammatory pathways. However the main reason for biological TNF inhibitor treatment dropouts is associated with loss of efficiency. It still remains unclear whether the replacement of such biological drugs by another of the same therapeutic class is an advantageous choice. Moreover, standardized criteria and improved schemes to treatment withdrawal are not well established. In this context, guidelines are useful to enable the patient individualized approaches to failures or sustained efficacy.

Objectives Evaluate the switching of biological agents at treatment failure and the withdrawal during remission of RA, established in guidelines and recommendations from various countries.

Methods Search achievement in Medline (PubMed), health systems and societies of rheumatology websites, to assemble substantial guidelines and recommendations printed during 2010 to 2014. Publications available in English, Spanish and Portuguese were evaluated.

Results It was possible to quantified the information available in 18 countries on five continents (especially in Europe and America), and the recommendations of EULAR (European League against Rheumatism). The methodology used by most publications included the review of the literature combined with consensus group of experts. Concerning switching biological agents after inefficacy, the major guidelines and recommendations advise use of TNF inhibitor as the first option behind failure with conventional synthetic Disease-Modifing Antirheumatic Drugs (csDMARD), and only anti-TNF failure justify the use of biological agent with another mode action. Some countries are considering the use of a second anti-TNF after its first failure, but more recent publications admit the selection of biological agents with others action mechanisms. Regarding the moment of discontinuation treatment in remission patients, caution is unanimously highlighted as well the monitoring of disease activity. However limit information was found about the best way to discontinue therapy and also differences on times required in remission or low disease activity were observed.

Conclusions Major worldwide guidelines and recommendations were unable to perform a full approach for the evaluated situations. The difficulty to establish switching and withdrawal biological drugs strategies could be, at least somewhat, derived from the type of information used on these documents. They are generally based on systematic reviews of clinical trials, so the studies duration and performance do not allow additional clarification on the research topics. Therefore it still remains the need to monitoring such issues with other studies types in order to provide patients further safety.


  1. Atzeni F, Sarzi-Puttini P, Gorla R, Marchesoni A, Caporali R. Switching rheumatoid arthritis treatments: an update. Autoimmun Rev 2011;10(7):397–403.

  2. Tanaka Y, Hirata S, Saleem B, Emery P. Discontinuation of biologics in patients with rheumatoid arthritis. Clin Exp Rheumatol 2013;31(4) Suppl 78:S22–7.

  3. Kirwan JR, Boers M. Biological treatment in rheumatoid arthritis: when to stop? Lancet 2014;383(9914):288–9.

Disclosure of Interest None declared

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