A recently published systematic literature review sought to compare the effects of down-titration of biologics compared with standard dosing on clinical efficacy and health-related quality of life, and to evaluate the impact of decreased doses on the cost of RA treatment.
Biologic therapies have resulted in better treatment of rheumatoid arthritis (RA), and have allowed many patients to achieve remission. The efficacy of these therapies has allowed clinicians to consider down-titration (also referred to as dose reduction or dose tapering) for patients who have achieved remission or low disease activity (LDA), though rheumatology guidelines in the United States, Asia, and Europe all acknowledge the fact that the level of evidence guiding down-titration is moderate to very low.
A recently published systematic literature review sought to compare the effects of down-titration of biologics compared with standard dosing on clinical efficacy and health-related quality of life (HRQL), and to evaluate the impact of decreased doses on the cost of RA treatment.
The investigators, led by Chak Sing Lau, MD, conducted an electronic literature search of English-language references published from January 2000 to February 2015. Randomized controlled trials, non-randomized controlled trials, observational studies, and pharmacogenomics studies were eligible for inclusion and screened for risk of bias. The studies that qualified for inclusion evaluated adalimumab, certolizumab, etanercept, infliximab, and rituximab:
In terms of economic outcomes, most studies reported a decrease in cost with down-titration. One retrospective US cost analysis found, however, that patients with a decreased dose had a significantly higher number of inpatient admissions, physician visits, laboratory and diagnostic tests, and prescriptions.
Based on these findings, the authors concluded that down-titration can be successful in some patients with RA, and that down-titration generally decreases costs. However, because some patients are unable to retain remission or LDA after having changed their treatment dosage, care must be exercised so that these patients do not experience joint damage.