The edition · Rheumatology
Stepwise biologic tapering held low disease activity in rheumatoid arthritis for 24 weeks, early peripheral spondyloarthritis shows drug-free remission at ten years, and lupus biologics compared
A 348-patient noninferiority trial supports structured tapering of biologic and targeted DMARDs in stable rheumatoid arthritis, a ten-year follow-up of a small trial finds one in three patients with early peripheral spondyloarthritis drug-free, and a real-world comparison finds rituximab and belimumab similar in lupus.
The edition in brief
In a 24-week open-label noninferiority trial of 348 patients with rheumatoid arthritis in sustained low disease activity on biologic or targeted synthetic DMARDs, stepwise tapering maintained low disease activity in 88.2% against 89.6% with continuation (risk difference -1.43%, 95% CI -8.09 to 5.23; margin -10%); some disease activity measures favoured continuation and most flares regained control with re-escalation. A ten-year follow-up of the CRESPA trial of golimumab versus placebo in early peripheral spondyloarthritis assessed 49 of 60 patients: 81.6% were in clinical remission and 30.6% in drug-free remission, with higher odds of drug-free remission in those without psoriasis (OR 9.1, 95% CI 1.8-50); this is a small descriptive follow-up. A single-centre observational comparison of 175 rituximab and 58 belimumab courses in lupus found similar rates of low disease activity (adjusted HR 0.92, 95% CI 0.57-1.48), with higher drug survival for belimumab only among second-line users (HR 1.34, 1.03-1.77). An external validation of prediction models in 217 patients from the MAINRITSAN trials found that a relapse score gave a borderline hazard ratio of 1.91 (95% CI 0.97-3.76) and an infection score gave 2.93 (1.28-6.72), which may help individualise decisions about extending rituximab maintenance in ANCA-associated vasculitis.
Structured tapering of biologic and targeted DMARDs was noninferior for 24 weeks in stable rheumatoid arthritis
Consider stepwise tapering of biologic or targeted DMARDs in stable low disease activity with a clear re-escalation plan, recognising the evidence covers 24 weeks.
Ten years after early treatment, one in three patients with peripheral spondyloarthritis was drug-free
Consider early treatment in peripheral spondyloarthritis and discuss supervised drug withdrawal only after sustained remission, recognising this evidence is small and descriptive.
Rituximab and belimumab reached low lupus activity at similar rates in a single-centre registry
Treat this as supporting either biologic in lupus where guidelines allow, with choice driven by disease features, access and cost.
Screen for hepatitis B and tuberculosis before starting a biologic
Check hepatitis B and tuberculosis status before the first biologic dose.
Relapse and infection scores may help decide who should extend rituximab maintenance in ANCA vasculitis
Consider using relapse and infection risk factors, including gammaglobulin level, to individualise decisions about extending rituximab maintenance, within existing guidelines.
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