Background: Optimal treatment using Treat 2 Target regimen has reduced morbidity and mortality rates in RA patients. However the use of biological therapies is expensive and a huge financial burden on Health budgets.

Current guidelines suggest to consider tapering biological therapies in patients with sustained low disease activity¹.

There is a risk of overtreatment in this cohort, with potential risks from sustained immunosuppression of increased infection rates and the chance of malignancy.

Objectives: Studies have shown biologic tapering is possible. Some studies have performed progressive tapering using DAS28 scores, others with ultrasonography assessment².

We used a progressive tapering strategy in tapering biological DMARDS in a selected RA cohort in a busy UK University Teaching Hospital, using ultrasound to guide the tapering process throughout and for detecting early recurrence during longer term followup.

Methods: Inclusion Criteria: Patients identified from routine clinic appointments as being either in clinical remission (DAS 28<2.6), or with low disease activity (DAS 28<3.2 and no swollen joints), and with no flares of their RA for at least 12 months.

Assessment: At each clinic visit the patients’ joints were examined, a DAS 28 and HAQ completed. Ultrasound was performed on hand and wrist joints (MCPJ’s, PIPJ’s, Wrists) in both Grey scale and Power Doppler to assess for inflammation. Biologic medication was progressively tapered according to results. Adalimumab was tapered to ‘3 weekly – 4 weekly – stop’ and Etanercept to ‘2 weekly – 3 weekly – stop’. Patients were given 3 monthly appointments. If patient flared or Ultrasound showed active synovitis, tapering was stopped and medication adjusted according to the findings. Pateints were followed up for a year at 3 monthly intervals, a year at 6 monthly intervals and then referred back to routine outpatient clinic.

Results: 28 patients were identified on Adalimumab and 8 on Etanercept.

Adalimumab: 17 patients (61%) stopped completely. At the time of writing, 16 (94%) remained off at 6 months. 12 (71%) at 12 months and 5 (29%) for >23 months. 6/17 flared and had to restart medication – 3 returned to a 4 weekly dose, 1 to 3 weekly and 2 to 2 weekly. 11/17 (65%) remain off medication.

At present 7 patients (25%) are on a 4 weekly dose, 1 (4%) patient is on a 3 weekly dose and 9 (32%) remain on 2 weekly.

Etanercept: 4 patients (50%) stopped completely. 1 of these has remained off for over 12 months and 1 over 24 months. 1 of these patients returned to weekly injections within 4 months

1 patient (12.5%) is on a 2 weekly dose and 4 (50%) remain on weekly

The management of 72% of patients was optimised using Ultrasonography. Ongoing cost savings as a result of tapering were in the region of £250,000.

Conclusions: Our study shows Ultrasound significantly aided in successful biologic tapering. It helped in selection of appropriate patients, as well as in monitoring during/after tapering. It also resulted in significant cost savings in the region of £250,000

References:

1. Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 73(3):492–509.
2. Alivernini S, et al. Tapering and discontinuation of TNF-alpha blockers without disease relapse using ultrasonography as a tool to identify patients with rheumatoid arthritis in clinical and histological remission. Arthritis Res Ther 18:39.

Acknowledgements: Rheumatology Unit GGH

Disclosure of Interest: None declared

DOI: 10.1136/annrheumdis-2018-eular.5199