Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors.

Objective: To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs).
Methods: Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses.
Results: Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007).
Conclusion: The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.
Competing Interests: Competing interests: LT: Speakers fee from Janssen, Roche, Novartis, Pfizer, UCB and Eli-Lilly, consultancy fee from Janssen. MO: research support, consultancy fees and/or speaker fees form Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB. LJ: Speakers fees and consultancy fees from AbbVie, Eli-Lilly, and Novartis. UMO: consultancy fees from Eli-Lilly, Roche, Novartis, speakers fee from Roche. SK: research support from AbbVie, MSD and Novartis. DG: Speakers fee from Eli-Lilly; AH: speakers fee from Eli-Lilly; KA: speakers fees and advisory board membership fees from AbbVie, Cellgene, Pfizer, Novartis, Roche, Berlin Chemie, Eli-Lilly and MSD; MB: research support, consultancy fees and/or speaker fees from Image Analysis Group, Esaote, Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics, Chondrometrics. MLH: grants from Bristol-Myers Squibb, AbbVie, Roche and Novartis, grants and personal fees from MSD, Biogen, and Pfizer, and personal fees from Eli-Lilly, Orion Pharma, CellTrion, Samsung Bioepis, Janssen Biologics B.V.
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