The final portion of the presentation dealt with advice on medication tapering and treating to target while keeping patient views in mind. With regard to tapering medication in patients who have been at target for at least six months, the ACR guideline conditionally recommends continuing DMARD therapy over tapering. However, if a compelling reason to taper exists, such as patient preference or comorbidities that may benefit from reducing medication burden, then dose reduction is conditionally recommended over gradual discontinuation, and gradual discontinuation is conditionally recommended over abruptly stopping DMARD therapy.2
Dr. Bingham advocated for the use of an atherosclerotic cardiovascular disease risk calculator to assess which patients may or may not be good candidates for treatment with JAK inhibitors.
Patient Care
With respect to treating to target, the goal should be remission of disease or low disease activity. Achieving these goals involves shared decision making between patients and physicians. This approach means patients should be able to understand the options available to them, the pros and cons of those options, and the ways in which their own goals and treatment preferences guide their care.
From a patient perspective, important considerations may include symptoms, such as pain and fatigue; physical function; valued life activities and roles; independence; avoidance of side effects; and financial costs. Because the clinical goals of the rheumatologist may not always include these objectives, it’s important that an open dialogue exist between patients and doctors to enhance trust and understanding, which are imperative to the therapeutic relationship.
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.
References
- Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):685–699.
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2021 Jul;73(7):1108–1123.
- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016 Jan;68(1):1–26.
- Ytterberg SR, Bhatt DL, Mikuls TR, et al. Cardiovascular and cancer risk with tofacitinib in rheumatoid arthritis. N Engl J Med. 2022 Jan;386(4):316–326.
- Charles-Schoeman C, Buch M, Dougados M, et al. Risk factors for major adverse cardiovascular events in patients aged ≥50 years with RA and ≥1 additional cardiovascular risk factor: Results from a phase 3b/4 randomized safety study of tofacitinib vs. TNF inhibitors [abstract: 0958]. Arthritis Rheumatol. 2021 Oct; 73(suppl 10).
- Curtis J, Yamaoka K, Chen Y, et al. Malignancies in patients aged ≥50 years with RA and ≥1 additional cardiovascular risk factor: Results from a phase 3b/4 randomized safety study of tofacitinib vs TNF inhibitors [abstract: 1940]. Arthritis Rheumatol. 2021 Oct; 73(suppl 10).
