The edition · Rheumatology
In controlled RA, tapering raised flare risk by half and withdrawal more than doubled it
A meta-analysis of 27 publications and 5262 patients found de-escalation, especially of biologics, brought flares and radiographic progression without fewer adverse events. Plus who to keep on rituximab in ANCA vasculitis, statin-associated necrotising myopathy and a tocilizumab biosimilar supplement.
The edition in brief
A meta-analysis of randomised trials covering 5262 patients with rheumatoid arthritis in sustained control found that tapering DMARDs raised flare risk by about half (RR 1.56, 1.26 to 1.98), mostly from biologic tapering in the first nine months, while stopping them more than doubled it (RR 2.23, 1.83 to 2.94) at every time point. Both were linked to radiographic progression over longer follow-up, and neither reduced adverse events. Gradual tapering can be discussed with stable patients, but stopping is best avoided. External validation in 217 patients from the MAINRITSAN trials showed that a model using sex, age, ANCA status, relapsing disease, ENT involvement and prednisone dose predicted major relapse, mainly in PR3-ANCA disease, while an infection model including lung disease, diabetes, prior infections and IgG level predicted serious infection more strongly (HR 2.93). Together they can frame the decision to extend rituximab beyond 18 months. In a US cohort of 142 people with myositis, statin-associated necrotising myopathy carried higher mortality, but the excess faded after adjustment for age and cardiometabolic disease. The FDA approved a supplement to the licence of the tocilizumab biosimilar Avtozma on 29 September; the notice does not describe the change. The pearl covers infection screening before biologics.
Rituximab maintenance in ANCA vasculitis: risk scores for relapse and infection held up in MAINRITSAN
When deciding whether to continue rituximab beyond 18 months in ANCA vasculitis, weigh the patient's relapse risk against their infection risk explicitly.
Statin-associated necrotising myopathy: higher mortality, largely explained by age and cardiometabolic disease
Statin-associated necrotising myopathy carries higher mortality mainly through age and cardiometabolic disease; manage both the myositis and the vascular risk.
FDA approves a supplement to the tocilizumab biosimilar Avtozma licence
A licence supplement for a tocilizumab biosimilar was approved; it does not by itself change practice.
Before any biologic or JAK inhibitor: screen for TB and hepatitis B
Screen for latent TB and hepatitis B, including anti-HBc, before every biologic or JAK inhibitor start.
Controlled rheumatoid arthritis: taper with care, avoid stopping
In controlled rheumatoid arthritis, taper DMARDs cautiously if at all and avoid full withdrawal, which more than doubled flare risk.
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