Abstract
Two-thirds of patients with rheumatoid arthritis (RA) can achieve remission with modern disease-modifying anti-rheumatic drugs (DMARDs), albeit with toxicity risks and prescription/monitoring costs. Drug tapering is possible though risks arthritis flare, and clear guidance on tapering protocols is lacking. We aimed to assess the clinical and economic outcomes of DMARD tapering in a longitudinal cohort of RA patients.
30 patients with a clinical diagnosis of RA in remission (DAS28-CRP < 2.4 and no swollen joints) took part in the RheumatOid Arthritis DMard tAPering (ROADMAP) clinical service at Newcastle Hospitals from January 2023 to June 2024. Patients sequentially tapered DMARDs (conventional synthetic, targeted synthetic or biological) at 3-monthly clinic reviews according to a standardised schedule and recorded weekly RA Disease Activity Index-5 (RADAI-5) scores via the British Society for Rheumatology ePROMs web portal. Suspected flare was confirmed (DAS28-CRP > = 2.4 and/or > =1 swollen joint) at scheduled or patient-requested visits, with subsequent DMARD re-escalation and bridging intramuscular glucocorticoid where required. Clinical data were prospectively recorded up to a censoring date of 20/06/2024.
11/30 (37%) patients achieved drug-free remission for a median (IQR) [range] of 161 (32-210) [21-371] days, although four subsequently experienced a flare and restarted DMARDs (Table 1). A further 7 patients had an arthritis flare during drug tapering, with taper ongoing (7) or stopped (5) in the remaining patients. Where flares occurred, these did not exceed moderate disease activity levels. Where the 3-month post-flare review had occurred before censoring, remission was re-captured by all patients (8/8), often with a dose equal to (3) or lower than (4) baseline. Patient-reported disease activity, but not disability, was significantly higher at flare but returned to baseline within 3 months (median change from baseline in RADAI-5 [HAQ-DI] of + 4.60 (p < 0.01) [+ 0.50 (p = 0.06)] and +1.00 (p = 0.09) [+0.19 (p = 0.60)] respectively). Tapering saved £47,618 in drug costs over 17 months based on British National Formulary list prices, with patients tapering biological/targeted DMARDs saving a median of £5,028 per patient per year.
Our pilot data suggests that DMARD tapering is feasible with overall positive clinical outcomes and could generate considerable drug cost savings.
T. Bradley: None. J. Sim: None. K.F. Baker: Consultancies; KFB has received consultancy fees from Modern Biosciences Ltd. Grants/research support; KFB has received research funding/support from Genentech and Pfizer.
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