ARCTIC REWIND was a tapering study that looked at what happens when csDMARDs are tapered in patients in stable remission, which was defined as remission sustained for at least one year on stable doses of medications with no swollen joints at inclusion. Three-year data showed that halving the dose of csDMARDs and/or halving the dose and stopping the csDMARD after one year was associated with significantly lower rates of flare-free survival.5 However, it’s worth mentioning that it was possible to taper or stop csDMARDS in a subgroup of patients. Thus, shared decision making regarding flare risk in patients who want to try to taper off csDMARDs remains key.
As for biologics, ARCTIC REWIND TNFi looked at tapering TNF inhibitors in the same group of patients mentioned above, with continuation of csDMARDs.6 In the tapering TNF inhibitor group, 63% of patients experienced a flare within 12 months, compared with 5% of patients who continued their TNF inhibitor without changes.
The TOLEDO trial showed similar disappointing results when trying to reduce or space out the dosing of abatacept or tocilizumab.7 “It doesn’t appear to be wise to halve the dose or stop the biologic. If you’re on a [biologic] medicine you’ve got to kind of stay there,” Dr. McInnes remarked.
RA & Multimorbidity
For many of our patients, RA isn’t their only health issue. For example, obesity, cardiovascular disease and diabetes commonly affect our patients with RA, compounding the risk of comorbidity. And RA, in and of itself, increases the risk of developing cardiovascular disease.
Dr. McInnes shared that “evidence is growing for a critical interaction between RA and multimorbidity (two or more coincident conditions). In general, if you are multimorbid, you’ll have poorer outcomes and are more likely to die.”8
So what can we do about it? A lot. Options include, but aren’t limited to, controlling blood pressure, blood sugar, weight and cholesterol levels.9 “There are lots of actionable risks that you and I need to be actioning. I urge you to either do it yourself, or make sure the primary care doctor is doing it,” Dr. McInnes said.
Weight loss, in particular, is incredibly important because treating chronic diseases without tackling excess adiposity promotes multimorbidity.10 Dr. McInnes had some simple tips when it comes to having this conversation with our patients. He first urged us to “avoid stigma and start by asking if it’s okay to talk about weight.” Once consent has been obtained, assess the problem, agree on a plan and assist the patient in making small, positive changes. For example, Dr. McInnes advises his patients to “cut sugary drinks, add more fiber-rich foods proven to help weight loss, adapt the palate and add 500 steps per day initially—if pain/joints allow.”
