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Biological disease-modifying antirheumatic drugs (bDMARDs) have taken up an important role in the management of axial spondyloarthritis. Once stable remission or low disease activity has been achieved with bDMARDs, it may be possible to maintain this state with lower levels of these drugs. Studies consistently demonstrate that tapering of tumor necrosis factor alpha inhibitors (TNFi) is not inferior to full-dose continuation in terms of maintaining treatment response, while data for tapering of interleukin-17 inhibitors (IL-17i) is lacking. Complete discontinuation of TNFi and IL-17i, however, often results in relapse and should not be recommended at this moment. Clear safety benefits of tapering or discontinuation have not been shown, although studies were typically not designed to address this. Current evidence does not support specific tapering or discontinuation strategies, although stepwise disease activity-guided regimens do allow for a more personalized approach and might be preferred. The definition of what constitutes an appropriate disease state to initiate tapering or discontinuation is unclear, and requires further study. Also, reliable predictors of successful tapering and discontinuation have not yet been identified. Fortunately, if tapering or discontinuation fails, most patients are able to regain disease control when reverted to the original bDMARD regimen. Finally, most patients indicate that, when asked, they would be willing to try tapering if the rationale is clear and if it is in their best interests. The decision to taper or discontinue should be made through shared decision-making, as this could improve the likelihood of success.

Successful management of rheumatoid arthritis (RA) requires suppression of the autoimmune response, which results in synovial inflammation, cartilage and bone damage and is associated with a range of extra-articular manifestations including accelerated atherogenesis, cancer and sepsis. The strategy to achieve this is called ‘treat-to-target' and requires frequent patient review to escalate therapy until remission or at least low disease activity is achieved. Numerous therapeutic agents are licensed to achieve this, starting with glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, followed by four different mode of action biologic DMARDs (targeting tumour necrosis factor, interleukin-6, B cells and T cell co-stimulation) and targeted synthetic DMARDs (inhibitors of JAK). For newly diagnosed patients, especially if treated within 3 months of onset, the outlook is immeasurably better than two decades ago before the treat-to-target strategy and biologic therapies were introduced. As a consequence the outcomes for many newly diagnosed patients include preserved function, maintained quality of life and no impact on mortality. For patients with long-standing disease, further joint damage can be prevented and severe complications of RA such as vasculitis and amyloidosis are now a rarity. Nonetheless RA is an aggressive destructive disease and its tendency to relapse requires disease-long patient review and treatment optimization to maintain control.