Background In the era of biologics,increasing numbers of patients achieve full remission.Although biological agents play an important role in reducing morbidity associated with long-term disease of rheumatoid arthritis (RA),they also present risks associated with side effects,increased risk of infection and a significant cost to the Healthcare Provider. There is an increasing body of evidence supporting dose reduction in RA patients1 and, recently, European League Against Rheumatism (EULAR) updated their recommendations for the management of RA suggesting biologic dose reduction in stable patients2.
Objectives The aim of this study was to investigate the effect of Etanercept dose reduction on our symptom-stable RA patients. We wished to examine whether patients were receptive to the idea,what their preferred delivery timescales/dose would be and the outcome to the individual.
Methods Suitable RA patients (on Etanercept for >1 year with 2 consecutive Disease Activity Score (DAS)<2.6 over at least 12 months and no steroid therapy in the preceding 6 months) were identified by clinicians and reviewed by a Clinical Nurse Specialist (CNS) for suitability. No limits were set for DMARD use. Informed consent was obtained; patients were offered 4 choices of reduced dose and could withdraw and return to standard dose at any time. A DAS score was performed at baseline and at each follow up visit planned at 3, 6 and 9 months before consultant review at 12 months. Patients also received a telephone consultation by our CNS 6 weeks after starting dose reduction.
Results 50 patients met inclusion criteria and were invited to participate. Three patients (6%) declined due to concerns regarding potential flare. The most popular regime was 50mg fortnightly (n=24), followed by 50mg every 10 days (n=11), then 25mg weekly (n=10), and 50mg four weekly (n=2). In total, 9 (19%) patients discontinued dose reduction – 1 patient at 6 weeks and, by 3 months, a further 8 reported loss of symptom control. Of these 9 patients, 5 were on biologic monotherapy while 4 were taking concomitant DMARDs. On withdrawal, 7 resumed the full Etanercept dose while 2 elected to switch to the 10 day regime. All patients who reported loss of efficacy were in the 50 mg fortnightly group, demonstrating a 38% failure rate for this group.
Conclusions Our pilot study suggests that biologic dose-reduction is mutually beneficial for patients and healthcare providers. Patients are open to the concept of dose-reduction, and were reassured by easy access and frequent review by our CNS. Nurse-led monitoring offers patients a longer and more cost effective assessment, and frees resources for consultant-led commitments. Outcomes from six- and twelve-month follow-up are awaited and larger studies are needed to determine the optimal regime for dose reduction.
van Herwaarden N, den Broeder AA, Jacobs WJ, et al. Down titration and discontinuation strategies of tumor necrosis factor blocking agents for rheumatoid arthritis in patients with low disease activity. Cochrane Database Syst Rev2014;29;9:CD010455
J.S. Smolen, R. Landewe, F.C. Breedveld, et al.EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Annals of the Rheumatic Diseases, 73 (3) (2014 Mar), pp. 492–509
Disclosure of Interest None declared